Metastatic Spinal Cord Compression (MSCC) is a well recognised complication of cancer and a surgical emergency. We present the results of a prospective audit of process focusing on the timing of intervention for these patients from presentation/diagnosis to surgery. Prospective audit of all patients referred to a tertiary spine unit over 6 months (April –September 2010). All data captured on an excel database.Introduction
Methods
Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain. 56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met. 56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied. Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported.
Centre Hospitalo-Universitaire de Lille, Service de Neurochirurgie et Chirurgie du Rachis, Lille, France. Assessment of current thoughts regarding spinal fellowships amongst spinal fellows in the United Kingdom and abroad Qualitative analysis provides rich and contextual detail that cannot be borne out by quantitative research. We undertook detailed interviews amongst fellows who have varying fellowship experience both in the United Kingdom and abroad. Ten fellows, all of whom were approaching their Certificate of Completion of Training (or equivalent) in Trauma and Orthopaedic surgery, or just awarded the certificate. All undertaking/undertaken at least one 12-month fellowship. Qualitative experiences A large unit provides a breadth of pathology that may is usually not encountered in smaller units. Fellows who worked in such units felt confident that they would recognise a variety of pathologies, but did not necessarily feel confident in their surgical management. Operative exposure to deformity surgery, whilst not necessarily a future part of practice, was felt useful for the added technical skills it provides. Fellows attending a smaller unit, where they may have been the sole ‘spinal fellow’, reported greater satisfaction in operative experience. Interestingly, there was felt to be a ‘saturation point’, where a fellow perceived no further educational benefit from remaining in one particular unit. A fellowship in spinal surgery is useful in preparing for independent practice as a spinal surgeon. Large units provide skills that are applicable to several aspects of spinal surgery. There appears to be a difference in breadth and complexity of pathology versus operative experience.
The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome. Anonymous retrospective review We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’ An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome. A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%). Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693). The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409. Ethics approval: None; Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company
The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC. Retrospective analysis All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15. Neurological outcome and survival A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery. The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%. There was no difference in neurological outcome between the 3 groups. There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score.
To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC. Retrospective review All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3). Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups. A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86). The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03. When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05). When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009). There was no difference in survival or complications between the groups. Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates.
The ‘disc’ group was significantly younger than ‘degenerative’ group (49.4 yrs vs. 58.4 yrs; p=0.004). There were significant improvements in low back pain (LBP), leg pain (LP), and ODI at 2 months in all patients. At 5 years the disc group did better with both leg and back pain; whilst there was only a significant reduction in leg pain in the degenerative group. Over 90% (n=56) of patients had no operative intervention; a subgroup of 8 had further injections. Within the degenerative group, ODI and VAS deteriorate early on indicating that a second injection option in this group may be worthwhile.
At 3 months there was no significant difference in VAS or ODI between the groups. Only two trials reported ODI data at 6 months but a significant effect in favour of the control arm was noted (P = 0.040). Four of the five trials reported the need for further injection or surgery due to failure but no significant difference between the groups was found (P = 0.038).
Antibiotics are frequently administered prophylactically in spinal procedures to reduce the risk of disc space infection. There is still controversy, however, over which antibiotics are able to penetrate the intervertebral disc effectively and whether the charges on the antibiotics are important in determining their ability to diffuse into the negatively charged intervertebral disc. In a prospective randomised double blind clinical study, we examined the penetration of two commonly used antibiotics, cefuroxime (negatively charged) and gentamicin (positively charged), into the intervertebral discs. Twenty patients, randomised into two separate groups, received either 1.5g cefuroxime or 5 mg/kg gentamicin prophylactically two hours before their intervertebral discs removed. A blood specimen, from which serum antibiotic levels were determined, was obtained simultaneously with each discectomy. Clinical therapeutic levels of antibiotic were detectable in the intervertebral discs of all the ten patients who received gentamicin. Only two of the ten patients (20%) who received cefuroxime had quantifiable level of antibiotic in their discs even though serum levels of cefuroxime were at therapeutic levels in all ten patients. Our results showed that cefuroxime does not diffuse into human intervertebral discs as readily as gentamicin and suggest that the charge due to ionisable groups on the antibiotics is important in determining the penetration of antibiotics. We therefore recommend the use of gentamicin in a single prophylactic dose for all spinal procedures to reduce the incidence of post-operative discitis.
