Purpose. To question the reliability of Thoracic Spine pain as a red flag and symptoms of a possible cause of Serious Spinal Pathology (SSP). Methods. The clinical notes and Magnetic Resonance Imaging (MRI) results of patients presenting to the Sheffield Spinal Service with Thoracic spine symptoms but no signs were retrospectively reviewed over the period of 2 year (September 2008-August 2010). The clinical reason for request of Thoracic MRIs were noted and the patient notes were reviewed to determine their presentation, length of time of symptoms, age and also it was noted whether any other recognized red flag symptoms were present. Exclusion criteria consisted of patients referred with known SSP or myelopathic symptoms. Results. 57 thoracic spine MRI requests were made in total by the orthopaedic spinal teams for patients presenting with thoracic spine pain in the time period. 8 patients were excluded as per criteria as they were referred with known SSP as were 4 other patients with a history of previous cancer. 45 patients presented with thoracic spine pain but no other red flag signs or symptoms of these none had MRI evidence of serious spinal pathology or indeed anything pathological indicating the cause of their symptoms. Conclusion. The majority of those presenting to orthopaedic spinal clinic with thoracic spine pain alone with no other red flag signs have no pathological cause. Thoracic pain is a widely accepted indicator (red flag) of potential serious spinal pathology. The findings from this review would not support thoracic pain alone as an indicator of SSP

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries. By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?. Retrospective study. We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted. The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°. In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level

Introduction. The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires. Materials and Methods. Whilst positioned in the supine or lateral position, a routine supine anterior lumbar interbody fusion (ALIF), and/or antero-lateral ALIF (AL-ALIF) and/or lateral lateral interbody fusion (LLIF) is performed. The patient is then turned prone or kept in the single lateral position (SPL) for insertion of the posterior screws performed under robotic guidance. Intraoperative CT scan 3D images captured then are sent to the Robotic software platform for planning of the screw trajectories and finally use again at the end of the procedure to confirm screw accuracy. We identified 34 consecutive patients from October 2019 to January 2020 who underwent robotic assisted spine surgery. The demographic, intraoperative, and perioperative data of all these patients were reviewed and presented. Results. Of the 34 patients, 65 levels were treated in total using 204 screws. Of the 21 patients (60%) who underwent single-level fixation, 14 of them (67%) were treated at the L5/S1 level, 3 at L3/L4, 3 at L4/L5 and 1 at L2/L3 level. The remaining 13 patients (40%) underwent multi-level fixation, of which 4 were adult scoliosis. 15 underwent a supine ALIF approach, 1 underwent AL-ALIF, 8 patients underwent combined LLIF and AL-ALIF approach in a lateral decubitus, whilst 9 underwent pure LLIF approach (of which 3 patients were in the single position lateral) and one patient had previous TLIF surgery. The average estimated blood loss was 60 cc. The average planning time was 10 min and the average duration of surgery was 50 min. The average patient age was 54 years and 64% (22/34) were male. The average BMI was 28.1 kg/m. 2. There were no re-interventions due to complications or mal positioned screws. Conclusion. Minimally invasive spine surgery using robot-assisted navigation yields an improved level of accuracy, decreased radiation exposure, minimal muscle disruption, decreased blood loss, shorter operating theatre time, length of stay, and lower complication rates. Further follow-up of the patients treated will help compare the clinical outcomes with other techniques

Purpose and Background. Both overall spine shape and the size and shape of individual vertebrae undergo rapid growth and development during early childhood. Motor development milestones such as age of walking influence spine development, with delayed ambulation linked with spinal conditions including spondylolysis. However, it is unclear whether associations between motor development and spine morphology persist into older age. Therefore, these associations were examined using data from the MRC National Survey of Health and Development, a large nationally-representative British cohort, followed up since birth in 1946. Methods and Results. Statistical shape modelling was used to characterise spinal shape (L5-T10) and identify modes of variation in shape (SM) from dual energy x-ray absorptiometry images of the spine taken at age 60–64 years (N=1327 individuals; 51.8% female). Associations between walking age in months (reported by mothers at 2 years) and SMs were examined with adjustment for sex, birthweight, socioeconomic position, height, lean mass and fat mass. Later onset of independent walking was weakly associated with greater lordosis (SM1; P=0.05) and more uniform antero-posterior vertebral size along the spine (SM6, P=0.07). Later walking age was also associated with smaller relative anterior-posterior vertebral dimensions (SM3) among women whereas the opposite was found for men (P <0.01 for sex interaction). Conclusions. Spinal morphology in early old age was associated with the age that individuals began walking independently in childhood, potentially due to altered mechanical loading. This suggests that motor development may have a persisting effect on clinically-relevant features of spine morphology throughout life. Conflict of interest: None. Funded by the UK Medical Research Council (Grant MR/L010399/1) which supported FRS, SGM and AVP

The lordosis distribution index (LDI) describes distribution of lumbar lordosis, measured as the % of lower lumbar lordosis (L4-S1) compared to global lordosis (L1-S1) with normal value 50–50%. Maldistributed LDI is associated with higher revision in short lumbar fusions, 4 vertebrae1. We hypothesise maldistributed LDI is also associated with mechanical failure in longer fusions. Retrospective review of 29 consecutive ASD patients, aged 55+, undergoing long lumbar fusion, 4 levels, with >3-years follow-up. LDI, pelvic incidence (PI) and sagittal vertical axis (SVA) were measured on pre- and post-op whole spine standing X-rays (Fig A and B). Patients were categorized according to their pelvic incidence (PI) and postoperative LDI: Normal (LDI 50 80), Hypolordotic (LDI < 50), or Hyperlordotic (LDI > 80) and assessed for failure rate compared to normal LDI and PI <60. Mean follow-up 4.5 years. 19 patients had mechanical failures including junctional failure and metalware fracture. PI >60o was associated with higher mechanical failure rates (Chi^2 p<0.05). Hypolordotic LDI was associated with 82% mechanical failure (Chi^2 p<0.001), Hyperlordotic 88% mechanical failure (Chi^2 p<0.001) and Normal 8% mechanical failure (Table 1). Maldistributed LDI, whether Hyperlordotic or Hypolordotic, correlated with 10× greater mechanical failure rate compared to Normal LDI in long fusions. LDI is a useful measurement that should be considered, especially in high PI patients

Purpose and Background:. Healthy adults with a curvy (lordotic) lumbar spine were shown to lift a load from the floor by stooping, while straight (flat) spines squatted. Since skin-surface motion capture often misrepresents internal curvature this study calculated internal lumbar curvature during lifting in the same cohort and compared lumbosacral motion. Methods:. Magnetic resonance imaging (MRI) was performed in standing and bending forward to 30, 45 and 60°, with markers on the skin at L1, L3, L5 and S1. Lumbar spine shape was characterised using statistical shape modelling and participants grouped into ‘curvy’ and ‘straight’ spine sub-groups (N=8). On a separate day participants lifted a box (6–15 kg) from the floor without instruction while Vicon cameras tracked sagittal movement of L1, L3 and L5 skin markers. Sacral angle (to horizontal) was calculated from pelvic markers. Matching markers during MRI and lifting sessions allowed vertebral centroid positions (L1, L3, L5, S1) during lifting to be calculated using custom MATLAB code. Results:. The curvy group had more internal lumbar lordosis at pick up despite stooping to lift the load. From upright standing motion occurred earlier at the upper lumbar levels (L1–L3) compared with lower lumbar (L3–L5). During lifting straight spines had greater rigid-body motion of the entire lumbar spine compared with curvy spines who demonstrated more varied intersegmental motion with greater sacral flexion. Conclusion:. Individuals with very lordotic spines retained some degree of internal lordosis despite stooping when lifting. The lumbar spine appears more mobile at the upper levels, L1–L3, and constrained motion was seen in those with the least lordosis

Purpose and Background. Low birth weight is related to decreased lumbar spine vertebral canal size and bone mineral content later in life, suggesting that antenatal factors affect spine development. The purpose of this study was to explore associations between antenatal factors and lumbar spine morphology in childhood. Methods. Antenatal data and supine MR images of the lumbar spine were available for 161 children. Shape modelling, using principle components analysis, was performed on mid-sagittal images to quantify different modes of variation in lumbar spine shape. Previously collected measures of spine canal dimensions were analysed. Results. Almost 75 % of all of the variation in lumbar spine shape was explained by just three modes. Modes 1 and 3 described the total amount and the distribution of curvature along the spine, respectively. Mode 2 (M2) captured variation in vertebral shape and size; increasing mode scores represented flatter vertebral bodies with increasing anterior-posterior dimensions. We saw no significant associations between mode scores and birth weight z-scores, placental weight, gestation length and no effect of maternal smoking (P>0.05). Controlling for gestation length revealed a positive correlation between birth weight and M2 (P=0.02). Males, longer babies and those from heavier mothers had higher M2 scores (P<0.05). This sex difference remained even when controlling for the other factors (P<0.001). Modes 1 and 2 correlated with spine canal dimensions (P<0.05). Conclusions. Our results suggest that antenatal factors have some effect on vertebral body morphology but not overall lumbar spinal shape. Perhaps environmental factors during growth and genetics play a larger role in determining the overall spine shape. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: This work was supported by a studentship granted to the University and awarded to AVP

Background. The aim of the Groningen Spine Center (GSC) is to provide personalized and effective interventions to patients with spine-related disorders. The GSC comprises a multidisciplinary team to triage and treat patients most optimally. Aim. To investigate the patient reported clinical results of the treatments of the GSC during seven years of its existence. Patients and methods. The basis of this study is a natural cohort of all patients admitted to the GSC. Treatments existed of rehabilitation, surgery, anesthesiology, medication, referral to else, advice and self-management, or any combination of the above. Baseline characteristics, pain (Numeric Rating Scale; NRS), disability (Pain Disability Index; PDI) and quality of life (Euroqol 5-D;EQ5D) were obtained at baseline and discharge. Per calendar year, effects will be presented. Descriptive statistics, effect sizes and t-tests were calculated. Results are compared to the minimal clinically important change (MCIC) of the corresponding scales. Results. In total, 9.897 patients (43% male, mean age 49.2±16.1 yrs) were analyzed on T0, of whom 1.373 filled in a discharge questionnaire. All measures showed statistically significant changes (p<0.01), but for pain and disability mean changes were not always higher than the clinical important change. Effect sizes (d) for pain ranged between 0.44 and 1.01, for disability between 0.40 and 0.80, and for quality of life between 0.41 and 0.76. Conclusion. The Groningen Spine Center provides positive patient reported results over the past 7 years Effect sizes are moderate to high. The results are considered to be clinically important to patients. Non-response and regression to the mean may be sources for bias and should be topic for further research. No conflicts of interest. No funding obtained

Background. The factors influencing normal spine curvature in midlife are unknown. We performed an MR and plain radiograph study on well characterised, unselected twin volunteers from the TwinsUK register (. www.twinsuk.ac.uk. ) to determine the relative contributions of genetic and environmental factors to spine curve. Methods. T2 weighted MR scans and long spine standing radiographs were obtained at the same morning visit on twin pairs. Midline sagittal MR images were coded for 4 degenerative features. SpineviewTM software was applied plain films and calculated the angles of curvature. A classical twin study was performed. Multivariate regression analysis was used to determine the association between spine curves, LDD and confounders (age, body mass index). Results. Data were available on 110 monozygotic (MZ) and 136 dizygotic (DZ) female twins. Mean age was 64.3 years (range 40.1–79.3); age was associated with increasing lumbar lordosis (p=0.02). The AE model (comprising additive genetic and unique environmental factors) was the most suitable model for both lumbar lordosis and thoracic kyphosis (as determined by Akaike information criterion). Heritability estimates = 59% (42–71%) for lumbar lordosis; and 61% (46–74%) for thoracic kyphosis. After adjusting for age and BMI, lumbar lordosis was significantly associated with a number of features of LDD (p<0.001) including disc signal intensity and osteophytes. Conclusion. The twins are known to be representative of women in the general population. Lumbar lordosis and thoracic kyphosis of the spine have considerable heritable component in females suggesting that a search for individual gene variants would be a reasonable next step. This abstract was presented at 14th Congress of the International Society for Twin Studies. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Introduction. A minority of patients with chronic low back pain (CLBP) account for a majority of disability and costs. This subgroup has potentially most to gain from effective treatment. The Groningen Spine Cohort will provide a 10-year prospective insight into the burden of CLBP for patients referred to multispecialty tertiary spine care in the Netherlands. This study reports first baseline results. Objective. To study the personal and societal impact of CLBP in patients visiting the UMCG tertiary spine center. Patients. Adult patients with CLBP. Methods. Patient-reported baseline questionnaire and health insurance costs one year prior to visiting the Spine Center. Primary outcomes: NIH minimal dataset Impact Stratification score (range 8–50), functioning (Pain Disability Index, PDI; 0–70), quality of life (EuroQol-5D, EQ5D; -0.33–1.00), work ability (single-item Work Ability Score, WAS; 0–10), work participation (absenteeism, disability), and health insurance costs. Descriptive statistics were applied. Results. N=1503 patients (age m=46.3, sd=12.8 years, 57% female) were included. NIH Impact Stratification m=35.2±7.5; severe impact (≥35) for 58% of patients. PDI = 38.2±14.1; EQ5D = 0.44±0.30; WAS = 3.8±2.9. Absenteeism: 43% of workers. Permanent work disability: 17%. Health insurance costs: med= €2432, IQR €4739. Discussion And Conclusions. In patients seeking multispecialty tertiary spine care, the personal and societal impact of CLBP is very high. Costs are substantially higher than what is already known about the burden of the average patient with CLBP. Clinical Message. More effective personalized stepped and matched care is urgently needed to reduce the burden of CLBP in a subgroup of patients seeking multispecialty tertiary spine care. No conflicts of interest. Sources of Funding: Funding from the University Medical Center Groningen

Background and Aim. Low back pain is highly prevalent, particularly in manual occupations. We previously showed that the lumbar spine has an intrinsic shape, identifiable in lying, sitting and standing postures, that affects the spine's response to load. Its effects on motion are unknown. Here we investigate whether intrinsic spinal shape is detectable throughout a greater range of postures and its effect on how healthy adults lift a weighted box. Methods. The lumbar spine was imaged using a positional MRI with participants (n=30) in 6 postures ranging from extension to full flexion. Active shape modelling was used to identify and quantify ‘modes’ of variation in lumbar spine shape. 3D motion capture analysed participants' motion while lifting a box (6–15 kg, self-selected). Results. Two modes accounted for 89.5% of variation in spinal shape, describing the overall curvature (mode 1) and distribution of curvature (mode 2). Within the first 9 modes, scores were significantly correlated between all six postures (r = 0.4−0.97, P<0.05), showing that intrinsic shape was partially maintained throughout. Individuals with straighter spines lifted with greater knee flexion (r = 0.4, P = 0.03) typical of squatting. Knee flexion negatively correlated with lumbar (r = −0.5 to −0.86, P<0.01) and pelvic flexion (r = −0.81, P<0.001). Those with curvier spines flexed significantly more at the back (r = −0.79, P=0.02) typical of stooping. Conclusion. In summary, individuals with straight spines squatted to lift while those with curvy spines stooped, indicating that the way we move to pick up a load is associated with the shape of our spine

Aim:. To determine if patients with coronal plane deformity in the lumbar spine have a higher grade of lumbar spine subtype compared to controls. Method:. This was a retrospective case/control study based on a review of radiological investigations in 250 patients aged over 40 years who had standing plain film lumbar radiographs with hips present. Measurements of lumbar coronal plane angle, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence were obtained. “Cases” with degenerative scoliosis (n=125) were defined as patients with a lumbar coronal plane angle of >10°. Lumbar spine subtype was categorised (1–4) using the Roussouly classification. Lumbar spine subtype was dichotomised into low (type 1,2) or high (type 3,4). Prevalence of lumbar spine subtype in cases versus controls was compared using the Chi squared test. Pelvic incidence was compared using an unpaired T-test. Predictors of lumbar coronal plane angle were identified using stepwise multiple regression. Significance was accepted at P<0.05. Results:. The prevalence of type 1–4 lumbar spine subtypes in the case group were 12.8%, 20.8%, 30.4% and 36% respectively and in the control group were 10.4%, 38.3% and 28% and 23.3% respectively. Types 3 and 4 lumbar spine subtypes were more prevalent in the cases group (66.4% vs 51.2% respectively, P=0.0207). Pelvic incidence was not significant different between groups (P=0.0594). No significant predictors of lumbar coronal plane angle were determined. Lumbar spine subtype (P=0.969), pelvic incidence (P=0.740), sacral slope (P=0.203) pelvic tilt (P=0.167) and lumbar lordosis (P=0.088) were not significant. Discussion:. Results show that neither the lumbar spine subtype nor pelvic parameters appear to have a significant influence on determining the coronal plane angle in the degenerative lumbar spine. Conflict Of Interest Statement: No conflict of interest

AO Spine Guideline for Using Osteobiologics in Spine Degeneration project is an international collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in spine degenerative diseases. It aims to formulate clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics. The current focus is the use of osteobiologics in anterior cervical discectomy and fusion surgeries. The guideline development is planned in three phases. Phase 1- Evidence synthesis and Recommendation; Phase 2- Guideline with osteobiologics grading and Validation; Phase 3- Guideline dissemination and Development of a clinical decision support tool. The key questions formulating the guidelines for the use of osteobiologics will be addressed in a series of systematic reviews in Phase 1. The evidence synthesized by the systematic reviews will be assessed by Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology, including expert panel discussions to formulate a recommendation. In Phase 2, osteobiologics will be graded based on evidence and the grading will be integrated with the recommendation from Phase 1, and thus formulate a guideline. The guideline will be further validated by prospective clinical studies. In the third phase, dissemination of the proposed guideline and development of a decision support tool is planned. AO-GO aims to bridge an important gap between quality of evidence and use of osteobiologics in spine fusion surgeries. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making process in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries

Purpose. To investigate associations between sagittal thoracolumbar spine shape with sex and measures of adiposity throughout adulthood. Methods. Thoracolumbar spine shape was characterised using statistical shape modelling on lateral dual-energy x-ray absorptiometry images, recorded for vertebral fracture analysis, of the spine from 1529 participants of the MRC National Survey of Health and Development, acquired at age 60–64 years. Associations between spine shape modes (SM) and 1) sex, 2) contemporaneous measures of overall and central adiposity (indicated by body mass index and waist circumference, respectively), 3) changes in total and central adiposity during earlier stages of adulthood and age at onset of overweight, were investigated. Results. Four of the first eight spine modes (SM) describing lumbar spine shape differed by sex; on average, women had more lordotic spines than men with relatively smaller but caudally increasing anterior-posterior (a-p) vertebral diameters. Greater BMI and waist circumference and earlier onset of overweight were associated with uneven (or snaking) spinal curvatures (SM2) and larger a-p vertebral diameters (SM3). Central adiposity was also associated with larger caudal disc heights (SM4) in women, especially increases between 36–43 years. Conclusions. Sagittal spine shapes differed by sex and associations with overall and central adiposity also differed. Overweight and greater central adiposity earlier in adulthood were particularly important, and were associated with a straighter but more unevenly curved spine with larger vertebrae and caudal discs heights, possibly explained by a chronic effect of increased mechanical loading on the spine. Conflicts of interest: None. Funding received from MRC

Traditionally, spinal surgeons placed radiographs on viewing boxes in a manner (PA) to replicate the view they would have at surgery. The introduction of digital Picture Archiving and Communications System (PACS) appears to have had marked impact upon this convention. Some Units have the ability to lock digital radiographs such that they are always viewed in the same manner and cannot be reversed. Following ‘two near misses’ we carried out a survey to confirm the previous practice with radiographs; to ascertain the current practice with PACS and to find out whether the variation in practice could lead to clinical mishaps and harm to patients. Questionnaires were completed by practicing spinal surgeons. Previous and current practice of viewing radiographs. Either actual or potential wrong side surgery. Opinions as to whether a single convention was important were recorded. 78 % Spine surgeons used to flip radiographs over prior to introduction of PACS. With PACS, 56 % spine surgeons flip the radiographs over in clinic and 72 % in theatre so to resemble viewing spine from behind. 56% Surgeons had nearly operated on the wrong side of the spine while 94 % have seen or heard of a patient operated on the wrong side. 72 % Spine surgeons agree that the radiographs should be flipped over so as to resemble the spine as viewed intraoperatively. There is need for a single convention in spine surgery to view radiographs to avoid potential clinical mistakes

Introduction. The British Spinal Registry (BSR) is a web-based database commissioned by the British Association of Spine Surgeons (BASS) in the UK. It allows auditing of spinal surgery outcomes, patient's safety and overall experience. The clinical data include patient's demographics which is entered into the Registry by medical staff, as well as patient-reported outcome measures (PROM) that is submitted to the Registry by the patient themselves at different time periods post-operatively. It has the ability to register Device and Implants as well as co-ordinate multicentre research. This study is to identify both the staff and patient compliance regarding to data submissions to the BSR at St. George's Hospital NHS Trust. Methods and Materials. Retrospective analysis of the BSR data for all spinal surgeries that was performed at SGH by the three Complex Spinal Surgery Consultants between 1st January 2017 to 31st December 2018. This study period allowed up to 12 months PROM data analysis. Staff and Patient compliance were analysed separately depend on the data they submitted. Results. 404 (n) spinal surgeries were performed over this two-year period. Surgical demographics: 39.4% (159/404) males and 56.2% (227/404) females, 4.5% (18/404) declined to be added. Age ranging from 6 to 92, mean age was 47.9. Staff compliance was 89.4% for the registration of patient data. Trauma and tumour patients were excluded as they are not required to complete any pre-operative PROMs. For the remaining patients, 35.8% (116/324) completed their baseline pre-operative PROMs. A steady decrease in patient compliance for post-operative PROMS was observed: 29.8% (2 weeks), 24.9% (6 weeks), 21.2% (6 months), 17.1% (12 months), and 16.6% (24 months). Conclusions. We identified a poor patient compliance in both pre-operative and post-operative PROMS. Patient questionnaire fatigue can occur over time which results in falling compliance to PROMS in 12 months and 24 months. Moreover, patients who do not provide an email address are less likely to fill in their PROMS. Satisfactory compliance for staff regarding to BSR utilisation are shown. Staff should aim to achieve a higher level of compliance as this will help to keep a record of all spinal surgeries that are performed and any complications that are encountered in a particular centre. Over the past three years, the BSR had introduced various schemes to drive up utilisation including a Best Practice Tariff in 2019. Part of the tariff will be withheld when staff failure to enter patients onto the Registry. Further research is needed to determine why there is such fall off especially with patient compliance and to elucidate potential measures to improve their compliance

Introduction. Spinal osteosarcomas are quite rare and the optimal treatment strategy is unknown. We report a series of 9 cases of osteosarcoma of the spine treated with intralesional resection and adjuvant combination therapy in order to evaluate their clinico-pathological correlation, recurrence rate and survival. Materials and Methods. Between 1980 and 2009, nine histologically confirmed cases of primary conventional osteogenic sarcoma of the spine were identified from Scottish Bone Tumour Registry. This prospectively collected registry database was retrospectively reviewed. Results. There were 9 cases with male predominance (77.7%) at a median age of 39 years (range, 16 – 73 years) and were anatomically distributed as 2-cervical, 6-thoracic, 1-lumbar and 1-sacral. Local and distant staging and histological grading was carried out in all. Seven patients underwent intralesional (including open biopsies) and 2 marginal resections. Seven patients received adjuvant chemotherapy and 8 adjuvant radiotherapy. The overall local recurrence rate was 66.6%. All but one patient died of the disease with a median length of survival of 30 months. The 2-year and 5-year survival rates were 66.6% and 22.2% respectively. Two patients who survived more than 5 years were male patients below the age of 40 years involving thoracic spine (one had a marginal resection without receiving any adjuvant therapy subsequently had a recurrence; other one underwent intralesional resection with adjuvant chemo- and radiotherapy, died with no evidence of disease). Conclusions. Spinal osteosarcoma in Scottish patients showed a higher median age, thoracic spine and male gender predilection with overall poor prognosis. Local recurrence did not affect the survival adversely, however patients older than 40 years and metastases at presentation showed poor survival compared to age under 40 and non-metastatic presentations

Background. Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders. Methods. We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected). Results. There were 9.4% surgical complications (most commonly dural tear, neurological sequelae, haematoma, infection) and 6.5 % general complications (most commonly cardiovascular, urinary, pulmonary, liver/GI). In the multivariable models, previous surgery significantly increased the odds of having a surgical complication (OR 1.148, 95%CI 1.051–1.253; p=0.002) and a medical complication (OR 1.185, 95%CI 1.074–1.307; p=0.001) i.e., for each previous surgery, the odds of a complication increased by 15% and 19%, respectively. Conclusion. We demonstrated a significant dose-response effect of previous surgery on the risk of incurring a complication during subsequent spine surgery. The results can be used by the surgeon when assessing the risk/benefit ratio of further surgery, for informing and consenting the patient. No conflicts of interest. No funding obtained

Background. Depression, anxiety, catastrophising, and fear-avoidance beliefs are some of the so-called “yellow flags” that predict a poor outcome in back patients. Many surgeons have difficulty assessing yellow flags, perhaps due to the complexity of existing instruments and time constraints during consultations. We developed a brief tool to allow the systematic evaluation of core flags. Methods. Data from 4 questionnaires (ZUNG depression (N=399); Hospital Anxiety and Depression Scale (Anxiety-subscale) (N=308); Pain Catastrophising (N=766); Fear Avoidance Beliefs (N=736)) were analysed to identify the respective single item that best represented the full scale score. The 4 items formed the “Core Yellow Flags Index” (CYFI). 1'768 patients completed CYFI and a Core Outcome Measures Index (COMI) preoperatively, and COMI 3 and 12mo later (FU). Results. The individual flag items correlated with their corresponding full-length questionnaires: 0.71 (depression), 0.81 (catastrophising), 0.77 (anxiety), 0.83 (fear avoidance beliefs). Cronbach's α for the 4 items was 0.79. Structural equation modelling revealed that CYFI explained a unique proportion of the variance in COMI at 3 months' FU (β=0.23, p< 0.001) and also at 12 months FU (β=0.20, p< 0.001). Conclusion. The 4-item CYFI proved to be a simple, practicable tool for routinely assessing key psychological attributes in spine surgery patients; it made a relevant contribution in predicting postoperative outcome. CYFI's items were similar to those in the “STarTBack screening-tool”, used in primary care to predict back pain chronicity, further substantiating its validity. Its wider use may help improve the accuracy of predictive models derived using spine registry data. No conflicts of interest. No funding obtained

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival. We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years. There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients). Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3. rd. of chondrosarcomas of the spine occured below 40 years of age and 3/4. th. in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates