With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.

Background

Persistent low back and leg pain is a common and highly disabling musculoskeletal condition. Many patients seek the opinion of a neurosurgeon with a view to surgical intervention. Few data are available which document the experiences of patients at these consultations.

Objectives:. To establish the demand, referral pathways, utility and patient satisfaction of a physiotherapy led post operative spinal surgery review clinic. Methods:. From July 2014 to January 2015 a pilot physiotherapy led clinic was established. The following clinic data was collected: number of patients reviewed, surgical procedure, outcome of clinic assessment, numbers requiring further investigation, numbers requiring review in the consultant led clinic and adverse events. A patient satisfaction survey was also administered to all English speaking patients. Patients were asked to rate the ease of getting through to the service by phone, length of wait, time spent with the clinician, answers to questions, explanation of results, advice about exercise and return to activities, the technical skills of the clinician, their personal manner and their overall visit. Data was anonymised and inserted into an excel spreadsheet for analysis. Descriptive statistical analysis was undertaken. Results:. 28 patients were reviewed in the pilot clinic. 17 (61%) patients were reviewed and discharged. 11 (39%) patients required discussion with the consultant. The outcome was: Referral for further imaging: n=5 (18%), referral to other specialist: n=2 (6%), consultant led OPD clinic review n=4 (14%) and surgical review of wound n=1 (4%). 84% (n=21/25) of eligible patients completed a post operative satisfaction survey. 86% (n= 18/21) rated their overall visit as excellent. There were no adverse events reported. Conclusion:. The pilot clinic has informed the development of a permanent physiotherapy led post op clinic in the National Neurosurgical Spinal Service and demonstrates the value of interdisciplinary care in this population

Purpose. To assess the impact of implementing a joint Neurosurgical/Orthopaedic Spinal on-call rota on the referral patterns to the Neurosurgical Department at James Cook University Hospital, Middlesbrough. Methods. A joint spinal rota was implemented at James Cook University Hospital in April 2008, to provide 24-hour on-call availability of a Spinal specialist. Using the Neurosurgical Referral Database (Microsoft Access), the referrals received for the 12 months prior to, and subsequent to, the implementation were analysed. Results. There was a 13.4% increase in total spinal referrals in the 12 months post-implementation of the new spinal rota, compared with pre-implementation. Total admissions from these referrals increased by 11.7%. There was an increase of 5.5% in lumbar degenerative referrals (including cauda equina referrals), a 10.5% decrease in cervical degenerative referrals, and most significantly, a 42.9% increase in spinal injury referrals, including fractures, and spinal cord injuries. Conclusions. The implementation of a joint Neurosurgical and Spinal Orthopaedic on-call rota for Spinal Surgery has resulted in the availability of a Spinal Consultant on-call 24hrs a day, 7 days a week to cover Spinal emergencies. The resulting change in referrals to the Neurosurgical Department has seen an increase in both referrals and admissions, although it is uncertain whether this is a result of a general increase in referral rate, or a direct result of the change in service provision

NHS Greater Glasgow & Clyde has six hospitals that provide an inpatient trauma service, but only two have facilities to receive patients by helicopter. The Southern General Hospital contains regional Neurosurgical and Spinal Injuries services and attracts the majority of major trauma delivered by helicopter. This study explores the impact that Emergency Medical Retrieval (EMRS) and Air Ambulance services have on the Trauma & Orthopaedic department at our Hospital. We examined the period 1. st. January 2010 to 31. st. December 2010 identifying Trauma & Orthopaedic admissions brought to our hospital by the Emergency Medical Retrieval and Air Ambulance services. These patients were identified from records kept by our Trauma Nurse Practitioner and an additional search of the hospital admissions database. Details of the admissions were extracted from this database, clinical records and various electronic patient records. Patients admitted to other departments were excluded from the study. 48 admissions (30 male, 18 female) were identified. Age ranged from 16-87 years. 16 patients had multiple injuries. 8 required High-Dependency or Intensive Care admission and there was 1 death in our cohort. 21 patients required surgery. In total, these patients required approximately 52.5 hours of operative time. These patients accounted for 373 inpatient days with an average hospital stay of 7.7 days (1-36 days). In addition, 25 patients have required a total of 35 outpatient appointments to date. This study quantifies the significant impact on inpatient and outpatient Trauma & Orthopaedic services from helicopter derived admissions. Some patients admitted under Neurosurgery and Spinal Injuries also undergo surgery, but were not included in the study, representing an additional workload. We believe this study supports an argument for additional investment in this growing trauma service, especially given the recent expansion of EMRS to cover the whole of Scotland

To assess concordance between hospital coding and clinician coding for patients undergoing spinal instrumentation procedures and determine if our coding systems result in accurate financial reimbursement from the primary care trust (PCT).

We conducted a one year retrospective review of 41 patients who underwent spinal instrumentation procedures. Data collected from IT systems included: operation description, clinician procedure code, hospital procedure code, Hospital Health Resource grouping (HRG), clinician HRG, instrumentation costs and PCT reimbursement fees. From this data we compared coding based re-imbursement fees and actual surgical costs, taking into account exact instrumentation prices.

In all cases the primary hospital and clinician coding values differed. Using the clinician code would have altered the HRG group in 16 patients. Using solely clinician coding would have generated less financial reimbursement than using hospital coding.

In 23 patients undergoing complex spinal procedures, instrumentation costs represented a significant proportion of the final fee obtained from the PCT, thus leaving a small proportion for the associated hospital stay costs. This suggests instrumentation costs are inadequately reimbursed from the PCT.

Hospital coding appears more accurate than clinician coding and results in greater financial reimbursement. On the whole, we found there to be insufficient reimbursement from the PCT. The variable and sometimes substantial cost of spinal instrumentation procedures results in inadequate reimbursement for many procedures. We feel the payment by results (PBR) scheme is suboptimal for such procedures and adequate reimbursement can only be achieved by direct billing on an individual case basis.

To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre.

Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank.

26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work.

Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery. Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature. Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants. 40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively. Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication

Cervical spine disorders represent a good proportion of the daily practice of many neurosurgeons. The rapidly increasing knowledge base on spinal conditions and the progressive complexity of surgical interventions appear to be generating a renewed interest in this evolving subspecialty among neurosurgical trainees. In order to assess the current level of spinal surgery training and conveyed competence in dealing with spinal disorders, a self assessment questionnaire was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Society) training courses. 126 questionnaires were returned with a return rate of 32%. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60,3% of total) representing 25 European nations. A separate analysis of the data pertaining to cervical spine disorders revealed 80% of the trainees completing their training in University hospitals with cervical spine injuries predominantly managed by neurosurgeons (75%). In their practical skill assessment, 78% of the senior trainees were competent in the treatment of cervical disc herniation and cervical spinal stenosis in their anterior microsurgical techniques. In emergency management of cervical spinal trauma, 45% of the senior trainees were competent in being able to perform procedures without direct supervision. Regarding skills in anterior and posterior cervical stabilisation techniques, 33% and 15% respectively were competent in performing as well as dealing with complications & difficulties that may arise. Spinal surgery training in European residency programs has clear strength in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation. Deficits are revealed in the management of spinal trauma and spinal conditions requiring the use of implants, with the exception of anterior cervical stabilisation. In order to achieve a high level of competency, EANS trainees advocate the development of a post-residency spine sub-specialty training program

Aim: Spinal stenosis is a known entity in achondroplasia and a need for screening for the symptomatic children was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether clinical and radiological imaging would identify the at risk group. Materials and methods: 205 achondroplastic children were treated at our service in the last 20 years. A prospective clinical screening programme for spinal stenosis which also included the MRI imaging of entire spine was however introduced only in 1996. 26 patients were available for this study. Case notes were reviewed for clinical symptoms and neurological signs. MR images were assessed for stenosis especially at Cervico medullary junction and lumbar level. Canal diameters were measured at all spinal levels from CMJ to lumbo-sacral junction. Neurosurgical interventions were recorded. An attempt was made to identify high risk factors that required surgical intervention. Results: Delayed milestones were observed in 7 patients. Positive history of back pain or radicular pain was obtained in 10 whereas 10 patients had symptoms of neurogenic claudication. Brisk reflexes and clonus were consistent findings. Severe foramen magnum narrowing was observed in 23 patients and 13 showed ‘kinking’ or ‘pinching’, suggesting severe compression. Of the 17 patients seen by neurosurgeons 6 required single or multiple surgical decompressions. Ventriculo-peritoneal shunt was inserted in 4. 5 children required CMJ decompression and one required lumbar canal decompression. There was a 7 mm difference in AP diameter measured on MRI at CMJ between the two non operated and operated groups. Female patients with delayed milestones and CMJ narrowing to less than 25 mm were identified as high risk. Conclusion: The cause of increased morbidity and mortality in young achondroplasts is attributable to severe CM compression. Sudden death can occur by acute or gradual progressive encroachment of respiratory centre at medulla oblongata. We were able to identify symptomatic patients early before developing myelomalacia and cord changes by screening all symptomatic children with achondroplasia. We propose that female gender, especially with delayed milestones as another high risk factor. We stress upon the importance of developing a nationalised selective screening programme with guidelines in specialist orthopaedic and joint multi-disciplinary Skeletal Dysplasia clinics

Introduction Symptomatic Thoracic disc prolapse (TDH) is a rare condition, with approximately 1 case per million population presenting per year. There are not many Spinal surgeons with a significant experience in the management of these lesions which necessitate a familiarity with the anatomy of the thorax and thoracic spinal cord. TDH is often diagnosed on modern imaging, but the indications for surgery in asymptomatic cases or in patients with spinal pain only, remain undefined. The natural history of TDH is not known and there is a poor correlation between the radiological and clinical presentation. The advent of newer minimally invasive endoscopic techniques for TDH may have reduced the incidence of open procedures for this condition, but may lead to an increase in operations performed for TDH, especially in cases where the surgical indications remain uncertain. In a small country like New Zealand it is especially difficult to build up a large series and to become very familiar with what remains a difficult operation. Methods The Neurosurgical experience with this condition in Auckland over the last ten years was reviewed. Clinical presentation, diagnostic imaging, surgical management and patient outcome were analyzed. Results Twenty-one patients were treated over the last 10 years. All had symptomatic TDH. Most operations were performed by the senior author. Patient age varied between 30 and 80, with mean age 50.8 years. There was a slight female preponderance (n=14). Most patients were of European ethnicity. Most patients had spinal cord or nerve root dysfunction, but local pain and sensation change were also noted. MRI was the mainstay in diagnosis, and CT scan was often also used. Surgical exposure was aimed at avoiding spinal cord manipulation and will be discussed. The surgical approach was via thoracotomy in most cases, costotransversectomy, pediculectomy and laminectomy. One case was treated conservatively. There was one case of postoperative paraplegia which will be discussed. There were no other permanent major neurological complications. Patient outcomes will be discussed in detail. Patients with motor weakness showed post operative improvement or full recovery. Pain and sensory loss symptoms were less likely to resolve. Complications that warrant discussion included temporary cranial nerve palsy, thoracic empyema, and long-term opioid addiction for pain. Discussion Over the past 10 years, a reasonable number of patients with TDH have been treated surgically without major incident. The surgical management of this condition remains a challenge. Younger spinal surgeons may not have the training to deal with these cases, which should be addressed. Endoscopic treatment has a steep learning curve, and may not be well suited to larger symptomatic TDH

Introduction A frequently asked medico-legal question is whether or not an accident or injury is responsible for the onset of nerve root pain. There is virtually no information available in the scientific literature, which answers this question. Methods. A search of the medical literature over the last 10 years was carried out. “Causes of disc protrusion” Medline. I designed and carried out a questionnaire of Members of the Spine Society of Australia, The Australian and New Zealand Orthopaedic Associations, and The Neurosurgical Society of Australasia. Each was questioned about symptoms, their quality, continuity, and time to onset after an accident. Reasons, which might lead the practitioner to conclude that there was no association, were documented, as well as the percentage of discogenic nerve root pain not caused by accident or injury,. Results 48% stated that there must be a continuity of symptoms from the time of the accident to the onset of root pain. 35% accepted that a maximum gap of 48 hours could be accepted before the onset of nerve root symptoms for a causal association to exist. The remainder said that up to 3 months of continuous ipsilateral somatic limb symptoms would be sufficient for an association between the accident and injury. Responders varied widely in their answer to the question “what % of acute discogenic nerve root pain is not caused by an accident or injury?” Responses ranged from 10 to 90%. Mean 58 %. Discussion There is a modest consensus about the circumstantial association of an accident or injury and the onset of nerve root pain. There is wide disparity about the causation of acute discogenic nerve root pain, in general

The syndromes associated with a narrow lumbar spinal canal are described and discussed. In thirteen cases two main groups were evident, the larger group having mainly backache and root pain, the smaller group having intermittent claudication. A method of recognising the narrow spinal canal on plain radiographs is described, and a comparison made with normal controls. The findings at operation are reported and the importance is emphasised of making a wide laminectomy for decompression. Our thanks are due to the neurosurgeons of the South-West Neurosurgical Unit, Mr G. L. Alexander, Mr D. G. Phillips and Mr A. Hulme, who kindly allowed us full use of their clinical notes. We would also like to thank Mr G. Banham for the reproductions, Mr E. Turnbull for the drawing and the secretarial staff for their patient co-operation