Background: Satisfaction following anterior and/or posterior spinal fusion varies greatly between individuals. The aim of this study was to assess patient satisfaction with the post-operative scars following surgical correction of scoliosis.

Methods: Prospective study; 31 patients (range 10–37 years), minimum of 2 months post-operation, interviewed in clinic or over the telephone using a questionnaire.

Results: Overall, 18 (58%) patients were disappointed with their scar; it was not what they expected, Patients with anterior scars or both anterior and posterior scars were the most disappointed groups.

39% of patients felt they were inadequately informed or not informed of the nature of scar. However, over 50% of those who had a specialist spinal nurse (SSN) consultation reported the scar to be as they expected. Scar length was the main source of disappointment. 55% reported their scars as being raised (keloid), particularly at the ends. Scar colour and shape was an issue for 23%, whilst 39% experienced prolonged healing. 19 patients had a pre-op consultation with the SSN, 11 did not get this opportunity, 1 declined.

Conclusion: Clearly there’s a need for improved education and understanding with regard to the nature of the scoliosis surgical scar(s). Input from a SSN is important and surgeons must clarify exactly what they mean when discussing operations with patients. This could be done with the aid of pictograms or leaflets detailing issues discussed in consultations along with the opportunity to meet patients who have already had surgery. These measures may lead to increased patient satisfaction with surgery.

Ethics approval: Audit

Interest Statement: None

Introduction: One of the main factors in the success of impaction bone grafting (IBG) in revision hip surgery is its ability to resist shear and to form a stable construct. Bone marrow contains multipotent skeletal stem cells and we propose that in combination with allograft will produce a living composite with biological and mechanical potential. In this study we looked at whether coating of the allograft with type 1 collagen followed by seeding with human bone marrow stromal cells (hBMSC) would enhance the grafts mechanical and biological properties.

Methods: A control group of plain allograft and three experimental groups where used to determine the effects that collagen and hBMSC have on IBG. The samples where impacted in standardised fashion previously validated to replicate femoral IBG, and cultured in vitro for 2 weeks. The samples then underwent mechanical shear testing and biochemical analysis for DNA content and Osteogenic activity.

Results: In isolation, both Collagen coating and seeding with hBMSC significantly enhanced the mechanical properties of the construct compared to the ‘gold standard’ of plain allograft. This was further enhanced (p=0.002) when the two processes are combined both with shear strength (245 vs. 299 kPa) and cohesion between the graft particles (46 vs. 144 kPa). The collagen coated group also showed increased osteogenic cell proliferation.

Discussion: This study has shown a role in the improvement of the mechanical properties of IBG coated with collagen and seeded with hBMSC. Collagen coating of IBG is a simple process and translation of the technique into the theatre setting feasible. The improvement in shear strength and cohesion could lead to earlier weight bearing for the patients and allow quicker recovery. The therapeutic implications of such composites auger well for orthopaedic applications. We are currently strengthening the above findings with an in vivo study.

Background: It remains unclear and controversial whether preoperative magnetic resonance imaging (MRI) in patients with adolescent idiopathic scoliosis (AIS) should be mandatory.

Aim: (1) To review our own practice, (2) conduct a national survey of United Kingdom Consultants, and (3) to perform a literature review.

Methods: Our own practice was established by identifying patients with AIS and examining whether an MRI scan was performed preoperatively. A survey of Consultants practice in the UK (British Scoliosis Members) was conducted by either an e-mail or telephone conversation. Finally, a literature survey was performed to establish current views.

Results: 118 patients with AIS were identified between 2003 and 2007. 78% of these patients underwent pre-operative MRI scans. Neural axis abnormalities were found in 8% of these patients. They included syrinx’s, chiari malformations, tonsillar herniation, cord tethering, central canal dilatation and undiagnosed spina bifida. Only 1 patient required intervention by the neurosurgeons. 92% of respondents to the national survey routinely performed preoperative MRI scans. The literature was not conclusive with regards to mandatory preoperative imaging.

Conclusion: Despite the literature showing little evidence, our survey shows a widespread consensus in clinical practice across the UK that routine preoperative MRI should be performed from a risk management viewpoint. It is mandatory in our unit to perform pre-operative MRI scans on all patients with AIS and would recommend that this becomes standard practice in all other units.

Ethics Approval: None/Audit

Interest Statement: None

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.

Introduction: Scoliosis surgery involves major blood loss, at times exceeding estimated blood volume.

Aim: To evaluate the effects of implementing blood conservation strategies (including cell salvage, controlled hypotension and anti-fibrinolytic drugs) on transfusion requirements in adult patients undergoing scoliosis correction surgery. To establish a protocol for cross matching of blood.

Study Design: We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients were anaesthetised by the same anaesthetist who implemented a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, antifibrinolytics used and blood transfused was noted.

Results: 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Anti-fibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

Conclusion: Use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures.

In our unit we do not have blood cross matched for anterior surgery alone.

Idiopathic anterior knee pain (AKP) is common in adolescents and young adults. Most believe that the origin of the problem lies in the patello-femoral joint. Hamstring tightness has also been attributed as an important cause.

The aim of our study was to compare biometric parameters in patients with idiopathic AKP and controls. We also wanted to assess whether there was a difference in the relative electromyographic (EMG) onset times of the medial and lateral hamstrings.

We prospectively recruited patients with idiopathic anterior knee pain in the age group 11 to 25. Patients, but not the control population, had AP, lateral and skyline radiographs taken to rule out other pathology.

We had 34 patients (60 knees) with a minimum one year follow up. There was no difference in the symptoms of patients who attended physiotherapy as compared to those who did not. Patients with knee pain had significantly more hip external rotation (63 deg) as compared to the control (47 deg) group (p=0.001). Patients also had significantly more hamstring tightness (p=0.04).

Surface EMG was recorded (17 patients and controls each) from the medial and lateral hamstrings during 3 repetitions of a maximal voluntary isometric contraction exercise with the knee at 45° of flexion. The lateral hamstrings contracted 48.7 m.sec earlier than the medial hamstrings in patients as compared to controls.

AKP is a multifactorial and self-limiting disorder. Earlier contraction of the lateral hamstrings may cause tibial external rotation and contribute to the symptoms. Our data suggests that physiotherapy did not significantly alter the course of the condition. We believe that increased hip external rotation may contribute to the symptoms by increasing medial facet stress.

Introduction: Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following the arthrodesis.

Aims and Objectives: To evaluate the functional and radiological outcome following percutaneous technique for SIJ fusion with HMA (Hollow modular anchor-age) screws.

Materials and Methods: 15 consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The Hollow modular anchorage (HMA) screws (Aesculap Ltd, Tuttlingen) packed with bone substitute were implanted percutaneous under fluoroscopic guidance

Results: The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post operative or radiological complications in any patient.

Conclusion: Percutaneous HMA screws are a satisfactory way to achieve sacro-iliac stabilisation.

Background: Radicular pain has been reported even in the absence of a compressive lesion. It has been postulated that annular tears provide a conduit for pro-inflammatory substances, which can leak around the nerve root causing radiculitis. A link between the side of back pain and the side of the annular tear has been reported.

Objective: To establish whether the side of the annular tear may influence the side of the leg in a non-compressive setting.

Methods and patients: We identified 121 patients from the patients referred to our unit with back and radicular leg pain. The mean age of the cohort was 50 yrs and 49% were male. All these patients were investigated with an MRI scan that demonstrated no compression of the nerve root. We used strict exclusion criteria to exclude the patients with any neural compression, previous lumbar operation, degenerative deformity or an associated pathology such as peripheral neuropathy.

Results: The annular pathology was described as annular tears (47 patients) and non compressive disc bulges (106 patients). The odds ratio for the concurrence of an annular tear causing ipsilateral leg pain is 1.05 and for a non-compressive disc bulge causing ipsilateral leg pain is 2.14

Conclusion: A non-compressive disc bulge is more likey to cause radicular symptoms than an annular tear. Though, both these annular lesions can cause ipsilateral nerve root symptoms.

Anterior Lumbar Interbody Cages are used to recreate the lumbar lordosis in scoliosis surgery as anterior instrumentation is usually kyphogenic. We report two cases in which an anterior release was performed and interbody cages were used.In both these patients the cage was displaced anteriorly by an incorrectly positioned pedicle screw during posterior instrumentaion. In one case the cage was retrieved and correctly repositioned from the back using a TLIF approach, in the other this was noticed only post-operatively and patient needed another anterior surgery. We recommend a lateral Image Intensifier screening for combined anterior and posterior cases in which anterior cages are used in addition to posterior pedicle screws to prevent this complication.

Objective: To do assess changes in patients’ symptoms and the operative plan.

Materials and methods: 147 patients on a spinal surgery waiting list were assessed at a mean wait of 15.8 ± 1.3 months. 89 (61%) were male and 58 (39%) were female at a mean age of 49.7 yrs (16–78). 123 patients had a degenerative condition (20 cervical; 03 lumbar); 20 patients were seen for scoliosis; 2 with a post-traumatic kyphosis and 1 each with ankylosing spondylitis and a psudarthrosis.

Outcomes assessed: Changes in patients symptoms; changes from the initial operative plan when listed; requirement for re-imaging due to the wait.

Results: 31 patients reported improved symptoms at the re-assessment, while 96 were worse off and 20 were unchanged. 137 had axial pain when listed which changed to 116 at review (p=0.0018). 130 had radicular pain when listed which improved to 80 on re-assessment (p< 0.0001). However 19 reported an increase in the axial and 17 in the radicular symptoms. 71 patients (48.3%) required to be re-imaged at the re-assessment due to changes in the clinical picture. 42 patients received the procedure as originally listed. 30 patients were taken off the list, 24 received a different operation, and 38 had an interim or a definitive needling procedure while 13 await a re-assessment.

Conclusions: On the basis of the observations on our cohort, 1 in 5 operations were cancelled; 65% had an increased severity of the symptoms and just 1 in 3 patients were operated as planned while 48% required re-imaging. A long wait inevitably leads to changed symptoms and a review of these patients is mandatory. The review and the re-imaging adds to the burden on the already over-loaded system.

Objective: To assess the temporal geometric sagittal profile changes on serial radiographs of fractures of the thoracic and thoraco-lumbar spine.

Materials and methods: We have included 103 patients with thoracic or lumbar fractures were treated at our unit between June 2003 and May 2006. The patients were suitable for non-operative treatment. The mean age of the cohort was 46.9±2.4 (16–90). The sex distribution was equal. 94 patients had a single level lesion. 19 fractures were in the thoracic spine; 64 in the thoraco-lumbar (T11-L1) and 29 between L2 and L5. The radiographs were scored using the AO classification by 2 senior orthopaedic trainees. The radiographs were analysed at the Spine Research Laboratory. The results were computed using Stat, a statistical software.

Results: The changes were assessed over a mean period of 5.6 mo (range 1–49 mo; 95% CI 4.1–7.1 mo). Weighted kappa score of 0.58 was computed for the primary fracture type and 0.22 for the fracture sub-types. The inter-observer rater agreement was similar to that reported in literature. 7 patients showed a significant collapse. We report the association between the fracture types and the extent of collapse. We have also assessed the association between the medium to long term symptoms, the fracture types and the extent of collapse at the fracture sites and the adjacent disc.

Conclusion: Some fracture sub-types are more likely to collapse and cause long term symptoms. Identifying these fractures at the outset would help clarify surgical indications.

Objective: To assess the correlation between the side of the annular pathology and the radicular symptoms, in the absence of a compressive root lesion.

Materials and Methods: 121 patients underwent MRI scan fro axial back and radicular symptoms. The mean age was 49.9 yrs (24–80). The sex distribution was equal. We excluded the patients that had a compressive lesion, previous operations, spinal deformity, spondylolyses, an underlying pathology (tumour, trauma or infection) or a peripheral neuropathy. Annular pathology was documented as annular tear or a non-compressive disc bulge with its location and side. We also recorded marrow endplate changes and facet arthrosis.

Results: Bilateral radicular symptoms were reported in 16 (13.2%): right side in 33 (27.3%) and left in 47 (38.8%) patients. Additionally, 82 patients (67.8%) had axial back pain. 33 patients (27.3%) were noted to have a right sided annular pathology (tear or bulge) and 72 (59.5%) had a left sided annular lesion. 21 patients (17.4%) had a central annular tear and 43 (35.5%) had a generalised disc bulge. 14 patients (11.6%) with right sided symptoms also had annular pathology, while 38 patients (31.4%) with left sided symptoms had a left sided annular lesion. There was no statistical correlation between the side of symptoms and the side of the lesion (r = −0.00066, p=0.994), any particular annular pathology (annular tear r=0.085, p=0.35; disc bulge r-0.083, p=0.36). There was no correlation between the axial back pain and the annular pathology (r=0.004; p=0.97) and facet joint or marrow end plate changes (r= −,29, p=0.76).

Conclusions: Although annular pathology can cause the radicular symptoms, our results suggest that they do not influence the side of the symptoms.

Introduction: Sacroiliac joint pathology can contribute to lowback pain and sciatica. Its frequency and significance is controversial.

Aims: The purpose of this study is to evaluate the incidence and clinical significance of positive SI joint pathology on MRI scans.

Methodology: 353 MRI reports and scans carried out over a one year period for backpain and sciatica were reviewed. Demographic data and clinical notes of patients who had positive SI joint pathology on MRI scans were analysed. Correlation between clinical suspicion of SI joint pathology and MRI findings was studied.

Results: 12 scans showed pathology in the SI joint, an overall incidence of 3.3%.8(66%) were males and 4(33%) females. Only 4(33%) of these patients had Plain Film abnormality. Average age of 41.2 years (33–54). One patient was known case of Ankylosing Spondylitis. Other positive pathology included oedema, sclerois and bridging osteophytes. Clinicians requested inclusion of SI joint in 43 patients. 8 of these were positive, an incidence of 18.6%. In 130 patients, the SI joints were imaged as routine. This yielded positive pathology in 4 patients (3%).

Conclusion: Our study concludes that 18.6% of patients who are suspected to have SI joint involvement clinically have positive pathology on MRI scans.

Routine inclusion of imaging of the SI joint as part of lumbosacral spine MRI for back pain and sciatica shows only 3% positive results.

SI joint should be imaged only if clinically suspected.

Aim: To assess if commonly used scoliosis instrumentation activates metal detectors at airport security gates.

Methods: 20 patientswho had travelled by air following scoliosis surgery were included. The type of instrumentation, number of journeys, body mass index and whether the alarm was triggered off by the airport security detector was recorded. We asked the patients opinion regarding provision of documentary evidence of surgery.

Results: 10 patients had posterior instrumentation, 5 patients -Paediatric ISOLA,4 patients had anterior instrumentation and one patient, anterior and posterior instrumentation. 12 patients (60%) had travelled more than four times by air following surgery corresponding to 48 passes through an airport archway detector.5 patients out of 20 had set off the alarm while passing through the metal detector everytime of which 4 had posterior instrumentation and 1 anterior instrumentation. None of the patients with ISOLA instrumentation set of the alarm. Two patients had set off the alarm every time they passed through the metal detector and both of them had posterior instrumentation. 14 patients(70%) suggested that we should provide documentary evidence of surgery to avoid delays in the airport security check. 25 % of patients set of the metal detector alarm following scoliosis instrumentation.

Conclusion: Patients with posterior instrumentation are more likely to set off the alarm compared to patients with ISOLA instrumentation. It is important to be aware that scoliosis instrumentation can activate airport archway detectors in our present security climate and to provide documentation to patients in order to avoid embarassment and delays.

Introduction: Scoliosis Nursing service was introduced at the Cardiff Spinal Unit in 2003 as part of a multi-disciplinary team to improve quality of care for the patients and their families.

Background: This nurse is a point of contact at pre-admission and discharge. She co-ordinates the peri operative care and liases with other team-members including physiotherapists, occupational therapists and dieticians. Information regarding type of surgery, pain management, wounds/dressings, investigations is offered.

Aims and Objectives: To assess patients’ and families perception and satisfaction with the various aspects of care provided by the Scoliosis Nurse.

Methods and Materials: From 2005 to 2006, 30 consecutive patients and families who had seen the Scoliosis Nurse filled a questionnaire. 25 questionnaires were completed. Response was collated by an independent observer.

Results: All (100%) respondents felt that the presence of a nurse in clinic was beneficial. (100%) reported that they had received adequate information and literature. 66% of the patients felt a pre admission ward visit would be beneficial. 63% felt that further information about discharge and aftercare would be helpful.

Conclusion: Thus the Scoliosis Nurse was perceived to be beneficial by the patients and the family. Based on the abovefeedback the patient Information booklet has been updated.

Paravertebral anaesthesia is a particularly effective, safe and reliable option in scoliosis patients undergoing anterior release in whom percutaneous epidural placement may be difficult to perform. A recent systematic review and meta-analysis of randomized trials has demonstrated that whilst paravertebral block and thoracic epidural insertion provide comparable pain relief after thoracic surgery, paravertebral block placement is associated with a better side effect profile, including a reduction in pulmonary complications, hypotension, nausea and vomiting and urinary retention. We describe a case of a 16 year old female patient who underwent staged correction of her thoracolumbar scoliosis. A paravertebral catheter was inserted under direct vision for continuous infusion post operative analgesia following the anterior release. 48 hours after surgery a swelling was noted in the groin, which was confirmed with ultrasonography as a fluid collection. The swelling resolved upon removing the paravertebral catheter. This suggests that it was caused by the local anaesthetic fluid tracking along the psoas muscle. Retroperitoneal infections, venous thrombosis, femoral hernia, femoral artery aneurysm and inguinal lymphadenopathy are other differentials. Ultrasonography was a fast and sensitive investigation to rule out these differentials and determined that fluid communicating with the abdominal cavity was the cause for this swelling. The infused local anaesthetic had tracked down into the femoral triangle and the swelling resolved upon cessation of the infusion.

Background: Thoraco-lumbar fractures without a neurological deficit are usually suitable for non-operative treatment. The main area of clinical interest is the deformity at the injured levels. The deformity may be evident at the time of presentation, though could be expected to progress in time.

Objective: Accurate assessment of the temporal behaviour in the geometry of the injured segments in non-operatively treated thoracolumbar fractures with normal neurology.

Materials: 102 patients with thoracolumbar fractures without a neurological deficit were treated non-operatively at our unit between June 2003 and May 2006. The mean age of our patient cohort was 46.9 yrs (16–90 yrs). Strict criteria were followed to determine suitability for non-operative treatment. Supine radiographs were performed at the initial assessment. Erect radiographs were performed when trunk control was achieved and at follow-up assessments thereafter.

Methods: Quality Motion Analysis (QMA) software (Medical Metrics Inc, Houston, Tx) was used to measure rotational and translation changes between the end plates using a validated protocol. The radiographs were standardised for magnification and superimposed from different time points. Transformation matrices were used to track the changes. The AO classification was used to classify the fractures by 2 independent observers.

Results: A median of 4 radiographs were analysed for each patient (range 2–9), at a mean follow-up of 5.6 mo (95% CI 4.1–7.1 mo). 92% of the cohort had sustained a 1 level injury. 76% of the injuries were between T12 and L2; 19% were in the thoracic spine. An inter-observer rating of 0.58 was obtained for the classification of the primary fracture type. The mean rotational change was −1.4855° ± 0.248° (95% CI: −0.994° to–1.976°). The mean anterior vertebral body height collapse was −4.3444° ± 0.6938 (95% CI: −2.695 to −5.724). The mean posterior vertebral height collapse was −0.7987 ± 0.259 (95% CI: −0.284 to −1.313).

Conclusions: We report the use of QMA software to track changes in the vertebral body geometry accurately. This has implications on the clinical aspects of management of thoracolumbar fractures based to progression of deformity that could be explored in future studies.

Background data: The Paediatric Isola system uses the philosophy of torsion-countertorsion force as a means of scoliosis correction. It aims to maintain this correction till such time that definitive fusion can be carried out.

Aim: This is a retrospective case series of our experience with the Paediatric Isola system and we evaluated the results of this system in the treatment of Scoliosis of various etiologies.

Methods: Twenty –one children,5 with neuromuscular,1 with Ehler-Danlos,5 with idiopathic,3 syndromic and 7 congenital treated with the Isola Instrumentation were studied.

Average age was 6.5 years(2–12). Average follow-up was 24 months (6m-36m).

Results: The average Cobb angle was 52° before surgery, 33.7° after surgery (64 % correction) and 32.5° (62.5% correction) at latest follow-up. The mean apical vertebral translation was 86% and 84% at post-op and latest follow-up. Stabilisation was most commonly perfomed from T2 to L4/L5. Three patients had implant complications, two had deep seated wound infections which necesssiated removal of implants in one case. Five of these patients have gone on to definitive fusions. Curve correction was best for primary thoracolumbar curves and lumbar curves. 2 patients with thoracic curves did not maintain correction.

Conclusion: The Paediatric Isola system is a safe and effective instrumentation in early management of a difficult and challenging sub group of scoliosis patients.

Background data: Previous studies have questioned the quality of information available on the internet. Internet research has proven to more prevalent among scoliosis patients as compared to other orthopaedic conditions.

Aim: Scoliosis websites identified by commonly used search engines were assessed for quality and medical accuracy.

Methods: The word scoliosis was entered into top six search engines and Websites ranked according to frequency. Five websites from the worldwide web and five from the UK only search were evaluated by medical professionals – 4 spinal consultants, 2 registrars, 3 nurses and 1 physiotherapist. 10 patients/carers who had scoliosis surgery also assessed these sites. A scale of 1 to 5 was used for ease of understanding, reliability, clinical correlation, adequacy and links and average score calculated.

Results: None of the top five UK websites figured in the top 5 WWW searchs. Scoliosis research society (SRS) and American Academy of Orthopaedic Surgeons (AAOS) website scored the highest by clinicians and patients in the www list. From the UK list, SAUK website scored the highest with both groups followed by Great Ormond Street Hospital (GOSH) website. We compared the assessment of websites by a healthcare professionals and by patients who had undergone treatment and showed no statistical difference in the scoring.

Conclusion: As treating clinicians it is necessary to educate patients by guiding them to reliable internet sites like SAUK and SRS.

Objective: Prolonged waiting time after being referred for a specialist opinion has plagued the NHS despite pressures to deliver optimum healthcare. We have assessed changes in clinical situation in patients referred to a spinal service while awaiting the first assessment.

Materials & Results: 89 patients were referred to our unit between Jan 2001 and December 2004. The gender distribution in this cohort was equal and the mean age was 50.7 yrs. The mean delay for being seen in the clinic was 28.4 mo (16–58 mo). Significant changes in the symptom pattern were noted in 46 patients, of which 8 patients reported radicular symptoms on a different side. In addition, 7 patients experienced an increased severity in the existing symptoms. 43 patients had been referred to us with an MRI. However due to the delay, 20 of these patients required re-scanning. Following the clinical assessment 25 patients were referred for Physiotherapy, 4 patients required a further clinical review and 44 patients were referred for further imaging.

Conclusion: The problem of excessive out-patient waiting time results in changes in symptom patterns and an increase in the severity of existing symptoms. The changes frequently results in an increased requirement of re-imaging.

Introduction: Restoration of vertebral height for burst fractures can be achieved either anteriorly, posteriorly or combined.

Aim: To biomechanically assess and compare stiffness of 1) posterior pedicle screws with Synex, 2) Synex+ Double screw+rod Ventrofix 3) Synex+ Double screw+ Single rod and 4) Synex+ Single screw+ Single rod in reconstructing an unstable burst fracture following anterior corpectomy.

Method: Fresh frozen calf lumbar spines (L3–L5) were dissected and L4 corpectomy performed. L3 and L5 were mounted on a plate and fixed. Loads were applied as a dead weight of 2Nm. The range of movement was measured using the Qualisys motion analysis system using external marker clusters attached to L3 and L5. Bony landmarks were identified with marker clusters as baseline. The movement was measured between the 2 marker clusters.

Five specimens were implanted for each group 1) with pedicle screw (into L3 and L5) and tested with/without Synex (expandable) cage anteriorly, 2) implanted with a Synex cage and Double screw+rod Ventrofix system, 3) Synex cage and Double screw+ Single rod Ventrofix construct and 4) Synex cage and Single screw+ Single rod Ventrofix system.

Results: Reconstruction of the anterior column with the combination of Synex and double rod Ventrofix produces a stiffer construct than the pedicle screw system in all planes of movement (p= 0.001 in rotation).

The double screw/ single rod system is less effective than the Ventrofix System but is comparable to the pedicle screw construct.

The single screw/ single rod construct leads to unacceptable movement about the axis of the inferior screw particularly in extension with a ROM much greater than the intact spine (p< 0.001)

Conclusion: Thus biomechanically we recommend Synex and double rod Ventrofix construct to reconstruct the anterior vertebral column following corpectomy for unstable burst fractures.

Aim: To determine the incidence of adjacent level osteophytes in patients who have had anterior cervical fusion using an anterior cervical plate as compared to those who are fused without an anterior cervical plate.

Design: We retrospectively reviewed the lateral radiograms of sixty two patients who have had an anterior cervical fusion with a minimum follow up of twelve months.

Materials and methods: We looked for the development of adjacent level osteophytes in these patients at their final follow up, which was generally at the time radiological fusion. There were 27 patients in the first group who had an anterior cervical plate used to fix the vertebrae in addition to the Cervios cage, while the 35 patients in the second group in whom only a Rabea cage was used for the fusion. The mean follow-up was 20.6 months (range 12–48).

Results: 64.3% of the patients who had an anterior cervical plate developed adjacent level osteophytes while none of the patients who have had the fusion without the cage developed the osteophytes.

Conclusion: We found the patients who had an anterior cervical interbody fusion using a plate had a significant risk of developing adjacent level osteophytes while this is not seen in patients who do not have the plate for the fixation.

Objective: To investigate the clinical outcomes, and the requirement of surgery following selective nerve root block performed for cervical radicular pain in patients with MRI proven disc pathology.

Methods: Thirty consecutive patients with cervical radiculopathy and correlating MRI pathology were studied. Mean age of patient was 46yrs (range 28–64yrs). Twenty nine of the thirty patients also complained of associated neck pain. All underwent fluoroscopically guided, selective cervical nerve root block with steroid (20mg Depomedrone) and local anaesthetic (0.5ml Bupivo-caine 0.25%). Radiographic contrast was used to confirm needle position. All procedures were conducted by the same clinician.

Pre and post procedure pain and physical function scores were noted using the standard SF 36 questionnaire, as well as whether subsequent surgery was required. Mean follow up time was seven months (range 2–13 months).

Results: 81% of patients reported an improvement in arm pain, and 66% in neck pain following the procedure. 77% of patients had an improvement in pain score (mean improvement 16 points). 68% of patients had an improvement in physical function score (mean improvement 20 points). At the time of follow up only one patient had undergone surgery for cervical radicular pain.

Conclusion: This study suggests that fluoroscopically guided selective nerve root block is a clinically effective interventional procedure in the management of cervical radicular pain, and may prevent the need for open surgery.

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards.

A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.

This prospective randomized multicenter study compares two methods of bone defect treatment in tibial plateau fractures: a bioresorbable calcium phosphate paste (Alpha-BSM) that hardens at body temperature to give structural support versus Autogenous iliac bone graft (AIBG).

One hundred and eighteen patients were enrolled with a 2:1 randomization, Alpha-BSM to AIBG. There was a significant increased rate of non-graft related adverse affects and a higher rate of late articular subsidence (three to nine month period) in the AIBG group.

A bioresorbable calcium phosphate material is recommended in preference to the gold standard of AIBG for bone defects in tibial plateau fractures.

This prospective randomized multicenter study was undertaken to compare two methods of bone defect treatment: a bioresorbable calcium phosphate paste (Alpha-BSM –DePuy, Warsaw, IN) that hardens at body temperature to give structural support and is gradually resorbed by a cell-mediated bone regenerating mechanism versus Autogenous iliac bone graft (AIBG).

One hundred and eighteen adult acute closed tibial plateau fractures, Schatzker grade two to six were enrolled prospectively from thirteen study sites in North America from 1999 to 2002. Randomization occurred at surgery with a FDA recommendation of a 2–1 ratio, Alpha BSM (seventy-eight fractures) to AIBG (forty fractures). Only internal fixation with standard plate and screw constructs was permitted. Follow-up included standard radiographs and functional studies at one year, with a radiologist providing independent radiographic review.

The two groups exhibited no significant differences in randomization as to age, sex, race, fracture patterns or fracture healing. There was however, a significant increased rate of non-graft related adverse affects in the AIBG group. There was an unexpected significant finding of a higher rate of late articular subsidence in the three to nine month period in the AIBG group.

Recommendations for the use of AIBG for bone defects in tibial plateau fractures should be discouraged in favor of bioresorbable calcium phosphate material with the properties of Alpha BSM. We believe further randomized studies using AIBG as a control group for bone defect support of articular fractures are unjustified.

A bioresorbable calcium phosphate material is recommended in preference to the gold standard of AIBG for bone defects in tibial plateau fractures.

Funding: DePuy, Warsaw, IN.

Background: More patients are turning to the Internet for health-related information. Studies indicate that this information is being used to make decisions about their management. The aim of this study was to assess the information available specific to scoliosis on the Web using four common search engines.

Methods: Four search engines (Google, Yahoo, Hotmail and Ask Jeeves) were used in scanning the Web for the following key word- “Scoliosis”. Both U.K. only and World Wide sites were accessed. Four Spinal Surgery Consultants independently graded each site for layout, content, relevance to patients as opposed to medical professionals, ease of use and links to other sites. Each point was marked on a scale of 0–2 and a total of 10 points available. Web sites were assessed via U.K. search engines and forty via World Wide search engines. Good was awarded to a site with a score of 7–10; an average awarded for a score of 4–7 and poor was given to a site with a score of 0–4.

Results: For the U.K. search engines, twenty sites were evaluated and five common sites identified (spineuniverse.com, S.A.U.K.org, orthoteers.co.uk, B.O.A.ac. uk and scoilosis.info). From these sites only two were given a rating of good. For the World Wide Web search engines eighteen sites evaluated and seven common sites identified (SRS, spineuniverse.com, scoliosis.org, orthinfo.aaos.org, iscoliosis.com, scoliosisrx.com and scoliosis-world.com). From these sites four were given a rating of good. It was evident that the Scoliosis Association of United Kingdom did not appear in three of the search engines but only in Hotmail.

Conclusion: These results suggest that there are good sites available for patients to access information with regards to their condition and treatment options but there are also very poor sites available where incorrect information is available. Commonly, unfamiliar users of the Web will not search U.K. sites specifically and could easily miss the S.A.U.K. site, which is an excellent site and was one of the two sites via the U.K. search engine awarded a good score. Obviously, there were more good sites via the World Wide Web due to the American healthcare system. We recommend that leaflets should be available to parents and patients with scoliosis with information from the BSS of the condition and available Web sites with good ratings. Also we recommend that these sites be linked to the Royal College of General Practitioners Web site to provide reference on good practice.

Background: Campbell et al from Texas have pioneered the use of Vertical Expandable Prosthetic Titanium Rib (VEPTR) in congenital scoliosis. Our centre is the first in the UK to use it and we report our experience of 5 cases done in the past 2 years. VEPTR works on the principle of expansion thoracoplasty and thoracic spinal growth of upto 0.8 cms/year has been reported by the developers of this device.

Methods: This case series includes one child who had the index surgery in America and is undergoing sequential expansion in Cardiff. All surgeries were done using a standard technique with monitoring of somatosensory evoked potentials. After appropriate soft tissue and bony releases, VEPTR was inserted and expanded by 0.5 cms to maintain tissue tension. Subsequent expansions were done as day case surgeries at 4–6 month intervals through a small incision over the VEPTR. We assessed clinical and radiographic assessment, which included – hemithorax height ratio, Cobb angle, interpedicular line ratio, space available for the lung.

Results: There were 3 males and 2 females with mean age of 6.3 years (range 0.9 to 9 years) at the time of index operation. Average follow up is 2 years (0.4 to 5 years). Average hospital stay for the index surgery was 5 days (4–7 days). All patients had mean of 3 expansions (range: 0–6). Mean improvement in the Cobb angle was seen from 48° to 36° at last followup. Space available for lung improved from a mean of 72 % to 86 %. Mean improvement in hemithorax height ratio was from 72.5% to 86%. One child had mild pain due to prominent metalwork; 2 children had transient brachial plexus neurapraxia, one of whom had progression of a secondary cervical curve and is awaiting further surgery for the same.

Conclusion: Our early results show good improvement of clinical and radiographic parameters. Transient nerve palsies have been well reported on the concave side and occur due to traction on the nerves as a result of increased height of the thoracic cage. This occurred in one initial case and has not been seen later. These results are encouraging but do indicate a learning curve.

Introduction: (1) Determine whether initial MRI findings correlate with clinical outcome.(2) Study the reproducibility of MRI measurements of large disc prolapses.(3) Estimate the ability to predict CES based on MRI alone.(4) Does CES only occur in degenerate discs?

Method: 31 patients with CES were identified and invited to attend clinic. 19 patients who underwent discectomy were identified. Digital photographs of all 50 MRIs were obtained. Observers: 1 Radiologist, 2 Spinal Surgeons and 1 Trainee did not know the number of patients in each group. Observers estimated the percentage spinal canal compromise on each view (0–100%), indicated whether they thought the scan findings could produce CES and commented on disc degeneration. Measurements were repeated after 2 weeks.

Results: 26 patients attended clinic – mean follow up 51 months (range 25–97). 12 of the 26 patients with CES had, on average, > 75% canal compromise. No significant correlations were found between MRI canal compromise and clinical outcome. Kappa values for intra-observer reproducibility of measurements ranged from 0.4–0.85 and inter-observer 0.63–5. Based on MRI, the correct identification of CES has sensitivity 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%. Over 80% of the CES causing discs were degenerate.

Discussion: Canal compromise does not appear to predict clinical outcome. MRI measurement reproducibility has substantial agreement. CES is a clinical diagnosis supported by an MRI scan. In less clear cases the presence of a large disc on an MRI scan supports a diagnosis of CES (PPV 84%). CES occurs in degenerate discs.

Purpose: To quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy.

Materials and Methods: Ten patients with large volume posterior thigh soft tissue sarcoma with known sciatic nerve involvement were reviewed between 1997 and 2004. Nine underwent surgery with extended epineurectomy of the sciatic nerve and planned marginal excision.

All patients underwent staging and follow up at Sarcoma Clinic with functional assessment and TESS evaluation.

Results: There were seven low and two high grade posterior thigh tumours of which nine were liposarcoma and 1 haemangiopericytoma. Two were recurrent and eight primary. There were five men and five women with a mean age of 77.

Nine patients underwent planned marginal excision. Sciatic nerve involvement was 13–30cm in eight cases and in one case the sciatic nerve was abutting the tumour throughout its length. There was soft tissue reconstruction in three cases using fascial adductor or gracilis graft for sciatic nerve cover and one with superficial femoral nerve and vein resection requiring ipsilateral saphenous reconstruction. The remainder underwent direct primary reconstruction.

Four patients underwent radiotherapy 46–60 Gy.

There was no local recurrence of disease within 14 – 96m follow-up. There was one patient with post radiation wound breakdown that resolved.

Three patients have died of unrelated causes. To date there has been no evidence of local recurrence of disease at FU.

Conclusion: Planned marginal excision of low grade large volume posterior thigh sarcomas with extensive sciatic nerve involvement can be successfully treated with preservation of the sciatic nerve without significant morbidity and resultant good limb function.

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach.

Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out.

Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up.

Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition.

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearson’s Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (χ² = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

Background: Long waiting lists in the NHS are a cause for public concern especially with regards to progressive conditions like scoliosis. We reviewed records to 61 patients to ascertain whether waiting time had any detrimental influence on their surgical management.

Methods: Retrospective review. Assessment of clinical records and radiographs of 61 patients who had scoliosis surgery over past two years was done by two independent investigators. Patient demographics, waiting times between referral and outpatient review and waiting time for surgery were collected.

Results: There were 41 females and 20 males with mean age of 11.8 years (range, 1– 22 years). Thirty-four patients had thoracic curves (28- right sided), 21 had thoracolumbar curves (19- right sided) and 6 patients had right sided lumbar curves. Mean Cobb angle at presentation was 58° (range,17°–90°) which increased to 71°(range, 30°–120°) at surgery. Average waiting time to be seen in the clinic was 16 months. Average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients (20%), of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° (range, 45°– 80°), which increased to a mean of 59° at surgery (range, 50°–92°). At presentation their Risser grades were: 5 – grade 0, 3- grade 2, 2- grade 4. These 10 patients had waited averagely 7.8 months to be seen in the clinic and for 11 months to have the surgery.

Conclusion: Significant curve progression occurred in 20 % of patients waiting to have scoliosis surgery. Ten of those required much more extensive surgery than originally planned. Long waiting times therefore have a detrimental effect on the surgical management of scoliosis patients.

Aim: To review our series of mid foot sarcomas with regard to excision of tumour, tolerance of radiotherapy and preservation of function.

Methods and results: We identified 6 patients with mid foot sarcomas treated in our unit. Synovial sarcoma was the commonest diagnosis. All the patients had stage 1 disease with no evidence of pulmonary metastases at presentation. Patients judged to have resectable tumour but preserving sufficient foot to be functional were spared amputation. They had excision of the sarcoma and immediate reconstruction using fascio-cutaneous free flaps. Complete excision was achieved in all cases. One flap was lost and repeated. In all patients, subsequent radiotherapy was well tolerated without significant complications. All patients remain disease free. All patients have returned to pre-operative functioning including walking and jogging. All except one have returned to work.

Conclusion: Patients and feet treated by wide local excision of mid foot sarcomas and reconstructed by free fascio-cutaneous flaps tolerate post-operative radio-therapy well, and return to near normal function.

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The severity was graded into none, mild, moderate and severe, depending on the cortical thickness, trabecular pattern, and the size of holes (absence of trabeculae) using sagittal, coronal and transverse sections of CT scan pictures. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearsons Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (Chi-square value = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation.

Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow.

Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used.

Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon.

Each surgeon graded 176 MRI images twice.

The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5

Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%.

The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%.

It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time.

Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers.

Introduction: Current evidence suggests that CES should be operated within 48 hours from onset of sphincteric symptoms in order to maximise chances of recovery. Measurement reproducibility of large disc prolapses and clinical correlations have not previously been studied.

Objectives: (1) Determine whether initial MRI findings correlate with clinical outcome (2) Study the reproducibility of MRI measurements of large disc prolapses (3) Estimate the ability to predict CES based on MRI alone.

Study Design: 31 patients with CES were identified, the case notes reviewed and the patients invited to attend clinic. Outcome consisted of history and examination, and several validated questionnaire assessments. 19 patients who underwent discectomy for persistent radiculopathy were identified. None had sphincteric symptoms. All had a significant surgical target. Digital photographs of all 50 MRIs were obtained showing the T2 mid-sagittal image and the axial image with the greatest disc protrusion. The Observers: 1 Consultant Radiologist, 2 Consultant Spinal Surgeons and 1 SHO did not know the number of patients in each group. Observers estimated the percentage spinal canal compromise on each view and indicated whether they thought the scan findings could produce CES. Measurements were repeated after 2 weeks.

Results: 26 patients attended clinic mean follow up 51 months (25 to 97). As expected, the % canal compromise differed significantly between the two groups (p0.001). 12 of the 26 patients with CES had, on average, over75% canal compromise. No significant correlations were found between MRI canal compromise and clinical outcome. Canal compromise did predict whether the patient would fail their Trial Without Catheter (p0.05). Based on MRI alone, the correct identification of CES has sensitivity 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%. Kappa values for intra-observer reproducibility ranged from 0.4 to 0.85 for sagittal compromise, axial compromise and correct prediction of CES. All three interobserver kappa values for these measurements were 0.64.

Conclusions: This is the largest radiological case series of CES with 4 years clinical follow up. Canal compromise on MRI does not appear to directly predict clinical outcome. Reproducibility of MRI measurements of large disc protrusions has substantial agreement. MRI could be of help in equivocal cases if the scan shows a large disc.

Study Design: Retrospective Series.

Objectives: To analyse loss of correction of the anterior wedge angle and the components responsible for the recurrence of kyphosis after surgical stabilisation of dorsolumbar fractures, and to assess the return of functional capacity in these patients.

Materials and Methods: Between January 1998 and March 2003, 34 patients had posterior stabilisation performed with the Universal Spine System (Synthes) for dorsolumbar fracture at a single level with no neurological deficit. There were 26 AO Type A fractures, 5 Type B fractures, and 3 Type C fractures. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The anterior wedge angle, the heights of the discs above and below the fractured vertebra, and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle and posterior). The values were normalised to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up were computed. Short Form 36 (SF-36) was used to assess the functional outcome in each.

Results: The mean follow-up period was 23.6 months (9 to 48 months). The mean anterior wedge angle was 10.1 ± 7.2 degrees in the immediate postoperative period and 17.1 ± 10.9 degrees at latest follow-up (p< 0.001). The mean loss of correction was 7.0 ± 8.5 degrees (−11 to 24) and this showed a linear relationship to the preoperative anterior wedge angle. Furthermore there was a linear increase in the loss of correction of the angle as the follow-up period increased. The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the anterior wedge angle showed significant correlation to the decrease in the anterior segment height at the fractured vertebral body level (Pearson’s coefficient r=0.53 significant at 0.01 level, p=0.001). The mean physical function score from SF-36 was 56.3 and the mean bodily pain score was 49.7. There was no relationship to the angle of kyphosis at follow-up to the physical function score (r=0.12, p=0.50) and the bodily pain score (r=0.14, p=0.44).

Conclusions: There is a progressive loss of correction (increasing kyphosis) after posterior stabilisation with instrumentation that roughly approximates the initial decrease in anterior height of the fractured vertebral body. The degree of loss of correction does not depend on the type of fracture. The loss of correction is related to the preoperative angle of kyphosis.

Study Design: Retrospective review.

Objectives: Rugby union has recently become a highly-paid professional sport. Players requiring anterior cervical discectomy wish to know the effect this will have on their career. To answer this question, the result of the above procedure in professional rugby players was studied.

Methods: A retrospective notes review and telephone interview were conducted on 19 professional rugby players who had a cervical discectomy between 1998 and 2003. Pre and post operative symptoms and numbers returning to rugby after surgery were assessed.

Results: Neck pain was eradicated in eight (42%) of the players, nine (47%) achieved partial relief and two were not helped. Brachalgia was eradicated in fifteen (79%) individuals, improved in two (10.5%) and two (10.5%) had no relief. Fourteen (74%) returned to rugby union, the majority at six months post operatively (range – five to 17 months). Thirteen (68.5%) returned to their pre-operative level of rugby; one dropped to a lesser division and five have never played rugby again (three due to physical inability, one due to club reluctance to insure and one because of a separate injury). Two of the players that returned to rugby have subsequently retired because of neck symptoms. They played three and two years post-operatively at first-class level.

Conclusion: Return to rugby union after anterior cervical discectomy is both likely and safe and therefore need not be a career ending procedure.

Study Design. A reliability study of the Modic classification.

Objective. To determine the reliability and reproducibility of the Modic classification for lumbar vertebral marrow changes.

Summary of Background data. In 1988, Modic with colleagues described two degenerative stages of vertebral marrow and endplate morphology. These were Type I (inflammatory phase) and Type II (fatty phase). Later in 1988, he added a third variety; Type III where there was marked sclerosis adjacent to the endplates. No formal reliability or reproducibility studies had been performed on the Modic classification.

Methods. This study involved five independent observers of differing spinal experience using the Modic classification to grade fifty sagittal T1 and T2 weighted MRI scans. The observers repeated the assessment at three weeks. Intra- and inter-observer reliabilities were assessed using kappa statistics.

Results. There were 7 type I, 40 type II, 1 type III and 2 normal levels. The individual intra-observer agreement was substantial or excellent with kappa values ranging from 0.71 to 1.00. The overall inter-observer agreement was excellent with a kappa value of 0.85. There was complete agreement in 78% of the levels, a difference of one type in 14% and a difference of two or more in 8% of levels. The level of experience of the observer did not correlate with a better score.

Conclusions. We have shown that the Modic classification is both reliable and reproducible. It is simple and easy to apply for observers of varying clinical experience. We therefore recommend its use in clinical research and practice.

Introduction and Aims: Odontoid fractures are quite common in the elderly following minor falls. As there are a few articulations in the upper cervical spine, degeneration in any one particular joint may affect the biomechanics of loading of the upper cervical spine. We aimed to analyse the pattern and relationship of odontoid fractures to the upper cervical spine osteoarthritis in the elderly.

Method: Between July 1999 and March 2003, 185 patients had CT scan of the cervical spine for cervical spine injuries. Twenty-three out of 47 patients over the age of 70 years had odontoid fractures. The CT scan pictures of these patients were studied to analyse the type of fracture and its displacement, the severity of osteoarthritis in each articulation in the upper cervical spine, namely lateral atlantoaxial, atlantooccipital, atlantoodontoid and subaxial facetal joints, evaluation of osteopenia in the dens-body junction and in the body and odontoid process of the axis, and calcification of the ligaments.

Results: Twenty-one of the 23 patients had Type II odontoid fracture with posterior displacement in seven (33.3%) and posterior angulation in nine (42.8%) patients. In these patients with Type II dens fracture, the atlantodens interval was obliterated in 19 (90.48%) patients, with only two of them (9.52%) having lateral atlantoaxial osteoarthritis.

Conclusion: Type II fracture is the commonest odontoid fracture in the elderly. Posterior displacement of the fracture is common in elderly, unlike the younger population. There is a significant relationship between the upper cervical spine osteoarthritis, apart from osteopenia, to the incidence of Type II odontoid fractures. Significant atlantoodontoid osteoarthritis in the presence of normal lateral atlantoaxial joints increases the risk of sustaining Type II odontoid fracture.

Introduction: Current evidence suggests CES should be operated < 48 hours from onset. MRI scanning is often not available 24 hours a day.

Objectives: (1) Determine whether MRI findings correlate with clinical outcome. (2) Study the reproducibility of MRI measurements of large disc prolapses. (3) Estimate the ability to predict CES based on MRI alone.

Study Design: 31 CES patients were identified,contactedand invited to follow up. Clinical outcome consisted of history and examination, and validated questionnaire assessments. 19 patients who underwent discectomy were identified. T2 mid-sagittal and axial digital photographs of all 50 MRIs were obtained. Observers did not know the number of patients in each group (1 Consultant Radiologist, 2 Consultant Spinal Surgeons and 1 SHO). They estimated the percentage spinal canal compromise on each view (0–100%) and indicated whether they thought the scan findings could produce CES. Measurements were repeated after 2 weeks.

Results: 26 patients attended clinic (mean follow up 51 months). There were no significant correlations found between MRI canal compromise and clinical outcome. Kappa values for the measurements ranged 0.52–0.85 and 0.61–0.75 for intra- and inter-observer reproducibility. Based on MRI alone correct identification of CES has sensitivity 67%, specificity 81%, positive predictive value 85% and negative predictive value 60%.

Conclusions: Canal compromise on MRI does not predict the outcome of patients with CES. Reproducibility of MRI measurements of large disc protrusions has substantial agreement. MRI could be of help in equivocal cases if the scan shows a large disc.

Over a five year period 50 patients required combined orthoplastic care out of 987 patients presenting with bone and soft tissue tumours. Thirty men, mean age 51 years, had their treatment reviewed at a mean follow up of 23 months (3–54 months) post surgery. All surviving patients completed the Toronto Extremity Salvage Score.

There were 23 bone and 27 soft tissue sarcomas, 4 were Enneking stage I, 41 stage II and 5 stage III. All tumours were removed by wide resection to achieve microscopically clear margins in 49. 9 endoprostheses were inserted. Soft tissue reconstruction involved 9 local flaps, 13 distant flaps (mainly muscle) and 8 free flaps (including 3 composite osseous flaps). 20 patients received adjuvant radiotherapy and 14 patients received chemotherapy.

Two endoprosthetic replacements required surgery for infection, one distant lap and one free flap required further surgery (6%). The mean disease free interval was 29 months (2–49 months). There were 6 deaths and pulmonary metastases occurred in a further 8 patients. Within this study period there was one episode of local recurrence, but no local recurrence in the group that had radiotherapy. 77% of surviving patients completed the Toronto Extremity Salvage Score and good to excellent function was seen in most cases.

Combined orthoplastic approach facilitates limb sparing surgery and early adjuvant radiotherapy.