Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

Aims

The aim of this study is to define a core outcome set (COS) to allow consistency in outcome reporting amongst studies investigating the management of orthopaedic treatment in children with spinal dysraphism (SD).

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Aims

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES.

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

Aims

The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture.

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery.

Cite this article: Bone Joint J 2019;101-B:355–360.

Aims

The purpose of this study was to investigate the prevalence of sarcopenia and to examine its impact on patients with degenerative lumbar spinal stenosis (DLSS).

Purpose and background:. Cauda Equina Syndrome (CES) is a rare condition which, even in the presence of prompt surgical decompression, can have devastating consequences for patients in terms of bladder and bowel dysfunction. The aim of this project was to develop a post-operative pathway for the assessment and management of bladder and bowel dysfunction in patients with CES. Method:. Beaumont Hospital performs a high volume of spinal surgeries. A small number are lumbar decompression surgeries due to CES. While sphincter function is routinely screened by a physiotherapist post-operatively, to date there has been no protocol in place for assessment and management of bladder and bowel dysfunction in this population. This project was carried out in collaboration with consultants in urology and colorectal surgery, as well as clinical nurse specialists in both areas. Results:. All patients undergoing lumbar decompression due to CES will be referred to a colorectal surgeon for post-operatively review and out-patient monitoring. A routine bladder ultrasound will be completed post-operatively to assess for urinary retention with a post void residual > 150 mls of urine indicating the need for referral to a urologist for in-patient review and out-patient follow-up. A patient education leaflet has also been developed. Conclusions:. A pathway has been implemented at Beaumont Hospital to ensure timely referral to specialised teams for both assessment and management of bladder and bowel dysfunction in CES. This pathway will ensure prompt access to specialised and supportive multi-disciplinary teams in the days/weeks/months/years post-operatively thereby minimising the emotional distress and health risks associated with secondary complications of CES

Pain catastrophising is an adverse coping mechanism, involving an exaggerated response to anticipated or actual pain.

The purpose of this study was to investigate the influence of pain ‘catastrophising’, as measured using the pain catastrophising scale (PCS), on treatment outcomes after surgery for lumbar spinal stenosis (LSS).

A total of 138 patients (47 men and 91 women, mean age 65.9; 45 to 78) were assigned to low (PCS score < 25, n = 68) and high (PCS score ≥ 25, n = 70) PCS groups. The primary outcome measure was the Oswestry Disability Index (ODI) 12 months after surgery. Secondary outcome measures included the ODI and visual analogue scale (VAS) for back and leg pain, which were recorded at each assessment conducted during the 12-month follow-up period

The overall changes in the ODI and VAS for back and leg pain over a 12-month period were significantly different between the groups (ODI, p < 0.001; VAS for back pain, p < 0.001; VAS for leg pain, p = 0.040). The ODI and VAS for back and leg pain significantly decreased over time after surgery in both groups (p < 0.001 for all three variables). The patterns of change in the ODI and VAS for back pain during the follow-up period significantly differed between the two groups, suggesting that the PCS group is a potential treatment moderator. However, there was no difference in the ODI and VAS for back and leg pain between the low and high PCS groups 12 months after surgery.

In terms of minimum clinically important differences in ODI scores (12.8), 22 patients (40.7%) had an unsatisfactory surgical outcome in the low PCS group and 16 (32.6%) in the high PCS group. There was no statistically significant difference between the two groups (p = 0.539).

Pre-operative catastrophising did not always result in a poor outcome 12 months after surgery, which indicates that this could moderate the efficacy of surgery for LSS.

Cite this article: Bone Joint J 2015;97-B:1546–54.

The purpose of this study is to find the clinical outcome of decompression of Cauda Equina presenting late in the course of disease. There were 33 males and 17 females with average age of 48 years, ranging from 25 to 85 years. All patients presented to us with a fully developed Cauda Equina syndrome (CES). All of them presented late with mean delay of 12.2 days. Time interval between bladder and bowel dysfunction and admission to hospital varied from 1 to 35 days. The average follow-up was 34.5 months, ranging from 12 to 60 months. There was no statistically significant difference in time of delay in surgery between the recovered and non-recovered group as tested by Student's t test. But there was a statistically significant positive correlation between duration taken for total recovery and delay in surgery. Anal wink as a predictor of bladder and bowel recovery also showed statistical significance, as patients with an absence had a poorer prognosis for bladder recovery. The result of surgery in CES is not as dramatic and fast as seen after routine disc surgery. Some improvement can be expected with decompression even in those patients presenting late and results are not universally poor as previously thought. The treating physicians of such patients should be aware that the recovery in this group of patients can take an exceptionally long time and hence should involve in constant reassurance and rehabilitation of the patient. Presence of anal wink is a very good predictor of bladder and bowel recovery

Introduction purpose and background. Implicit in the diagnosis of CES is the presence of leg pain with a spectrum of bladder and/or bowel disturbance and/or peri-anal sensory loss. Current research describes the clinical features of patients with radiologically confirmed CES, but the specificity of these features is not known. This study explores the accuracy of patient self reported bladder or bowel dysfunction and numbness of the bottom in individuals presenting with lumbar nerve root pain. Methods and Results. A retrospective review of patient completed questionnaires, of 281 consecutive patients with leg dominant back pain, presenting to an interface service. 26% of patients reported bottom numbness. 25% reported recent bladder or bowel (B/B) changes. Following a comprehensive assessment including anal tone testing 10 patients were referred to the spinal on-call service. Of these 1 had surgical decompression for radiologically confirmed CES. A review of the hospital records suggests that none of the remaining sample were subsequently admitted for CES within 2 months of the assessment. Individually bottom numbness and recent changes to the B/B had a sensitivity of 1 and a specificity of 0.73. When both numbness of the bottom and changes to B/B are reported the sensitivity was 1 and the specificity was 0.9. Conclusion. Self reported clinical features suggestive of CES are not uncommon in this highly selective population. Individually numbness of the bottom and changes to B/B were highly sensitive and had moderate specificity. However, when both bottom numbness and changes to B/B are reported, the specificity is also high. The potential for improved clinical outcomes for the individual identified with confirmed CES is emphasised. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Introduction. Displaced fractures in the sacrum are associated with other intra-pelvic organ injuries. There are some reports on short term outcome, however there is little knowledge about the long-term morbidity after these severe injuries. Aims of study. -. Describe neurologic deficits in the lower extremities and impairments involving the uro-genital, bowel and sexual functions a minimum of 8 years after injury. -. Compare the long-term results with our previously published results after one-year follow-up (1). Materials and methods. 39 consecutive patients with displaced sacral fractures were prospectively registered at Oslo university hospital, Ullevaal between 1996 and 2001. Tötterman et al. published 1-year results on 32 of the 39 patients(1). In the present study we followed 29 of these 32 patients for 8 years or more. The following evaluation instruments were used: Neurology: Sensorimotor function was classified according to ASIA score. Bladder function: Structured questionnaire with regards to frequency, urge or incontinence. Also, flowmetry and ultrasound were done to determine maximum flow and post-micturition volume. Bowel function: Structured questionnaire with regards to frequency, urge, diarrhea, constipation and incontinence. Sexual function: Open questions to address any problems associated with sexual function. For male patients, selected questions from the International Index of Erectile Function were used. For comparison with previous data from the one year follow-up we used the Wilcoxon Signed-rank test for non-parametric data. Results. Neurology: 26 patients had neurologic deficits in the lower extremities. Two patients were not testable and only 1 was asymptomatic. Bladder function: 5 had slightly changed, 11 significantly changed and 4 completely changed voiding pattern. Bowel function: 6 had slightly changed and 3 completely changed bowel pattern. Comparing our results with previous data showed deterioration in voiding function over time in 38%(p=0.005), improved bowel function in 28%(p=0.047) and no significant changes in neurological deficits (p=0.47). Sexual function: 45% reported sexual dysfunction versus 38% at the 1-year follow-up. Conclusion. Neurologic deficits, uro-genital and bowel dysfunction are frequent after displaced sacral fractures. Voiding and sexual problems deteriorated over time, while bowel function improved, and neurological deficits showed no significant changes. Pathologic bladder function may cause irreversible structural damage to the bladder, and subsequent impaired renal function. These problems should therefore be addressed early in the rehabilitation period and the patients must be followed by adequate expertise for many years after the injury

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring.

As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases.

In this study we aim to establish which symptoms and signs are able to reliably predict the presence or absence of cauda equina syndrome. Prospective collection of data was carried out over 10 months on all patients referred with suspected cauda equina syndrome(CES) to a single spinal unit. 28 patients were referred. MRI was normal in 4 (14%) patients. 4 (14%) had disc prolapse causing CES and 3 (11%) had spinal metastatic disease. All patients with CES presented with low back pain, unilateral sciatica, urinary dysfunction (painless retention 2, incontinence 2), altered perianal sensation and abnormal anal tone. 1 described constipation. Of patients without CES or malignancy 21 (100%) complained of low back pain, 19 (90%) sciatica (15 unilateral, 4 bilateral), 12 urinary dysfunction (incontinence 5, reduced sensation 3, painless retention 2, urgency 1, terminal dribbling 1) and 5 described altered bowel habit. 7 (33%) exhibited altered perianal sensation and 1 (5%) abnormal anal tone. The patients with spinal metastases all described back pain but no sciatica. 2 had urinary retention and constipation with 1 having abnormal perianal sensation and anal tone. This study suggests abnormal anal tone (sensitivity 1.0, specificity 0.95) and altered perianal sensation (sensitivity 1.0, specificity 0.67) are the most reliable predictors of CES. Thorough clinical examination is essential. Back pain with bladder and/or bowel dysfunction without sciatica should raise the suspicion of malignancy

A total number of 428 patients underwent surgical procedure due to different acquired spinal disorders. Conservative approaches were tried where it was indicated. When there was no improvement with conservative treatment then surgical procedures were adopted. It was a prospective study which was done in both Govt. and private hospitals irrespective of age & sex. Total period was from August 2002 to February, 2008. Age of the patients ranged between from 8–65 years. In this series male was more dominant than female. In this series main causes were traumatic, infective, degenerative & neoplastic disorders. Prolapsed Lumber Inter-vertibral Disc 202, prolapse cervical disc 15, unstable spinal injuries 86, Pott’s paraplegia 68, degenerative disc disease 18, spondilolisthesis 12 and neoplastic both primary & secondary were 9 cases. Fenestration & disectomy done in PLID and decompression and stabilization done in unstable spinal injuries. Instrumentation done as adjuvant to achieve early biological union of bone. In Pott’s disease when conservative treatment failed to improve, decompression and stabilization was done by thoracotomy specially in at thoraco-lumber tuberculosis. Clowards operation done in cervical disc prolapse & spinal canal stenosis. Laminectomy done in lumber spinal canal stenosis. In spondilolisthesis, laminectomy followed by stabilization done by bilateral pedicular screw fixation with or without inter-body bony fusion. Excellent and satisfactory results were achieved in incomplete unstable injuries. No neurological improvement detected in complete injuries. Maximum Pott’s paraplegia regained their neurological function and bowel bladder dysfunction except one who recovered her one limb function full but other limb become spastic. In PLID maximum patients improved immediately after surgery. Few patients required physiotherapy after surgery and improved later on. In Spondilolisthesis patients became symptoms free after decompression and in situ fusion by instrumentation. In complete spinal injuries no improvements were detected. Breaking of pedicular screws observed in two cases. Mal-position of screws in 5 cases observed in traumatic spinal injuries. Post operative discitis developed in 2 cases after PLID operation 2 cases required surgery second time due to recurrent PLID. Proper selection of cases is very important in spinal disorders. In incomplete spinal injuries satisfactory results can be achieved in maximum cases but in complete spinal injuries no neurological development are achieved but for early mobilization surgery is helpful. Maximum spinal disorders can be managed conservatively but surgical intervention should be done in earliest possible time when indicated

We analysed the influence of the timing of surgery (< 48 hours, group 1, 21 patients vs > 48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression.

Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%).

These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.