Purpose

To report a retrospective study of 103 cases of primary spinal infection, the largest ever such series from the UK, analysing presenting symptoms, investigations, bacteriology and the results of treatment.

Calcium and vitamin D are both of key importance for bone health, and their effects on bone appear to begin even in utero and continue throughout life. The dietary requirements for both calcium and vitamin D are different at different stages of the lifespan. Importantly, in Australia the bulk of vitamin D comes from manufacture of vitamin D in the skin from ultraviolet light exposure i.e. from sun exposure, as the amount of vitamin D in foods is low. Vitamin D deficiency is common at all stages of life and some groups are at particularly high risk. Adequate calcium intake and maintaining adequate vitamin D levels are important in childhood for maximising peak bone mass, but the effect of calcium supplementation on bone mineral density is small. The role of vitamin D supplementation in childhood outside of treating rickets is unclear, though there is potential for a clinically significant effect. Calcium and vitamin D supplements have been investigated for the primary prevention of osteoporotic fracture in the elderly. Calcium and vitamin D is effective at reducing non-vertebral and vertebral fractures in the institutionalised elderly but community-based studies show conflicting results. There is no evidence that calcium, vitamin D or the combination of calcium and vitamin D alone prevent fractures in those who have already sustained a low trauma fracture (secondary prevention) but calcium and vitamin D are both important adjunctive treatments in established osteoporosis i.e. in combination with other pharmacotherapies.

Introduction and aims: Familial aggregation of low back pain (LBP) symptoms has been described. However, this may be due to genetic factors or common exposure to environmental factors. This study evaluated the relative contribution of genetic and environmental factors to childhood LBP.

Methods: Data was collected from 1995 to 1998 from a national sample of 1790 Finnish twins aged 11-years. A validated pain questionnaire was used to assess LBP pain. Information was also collected on children’s perception of parent-child relationships, parenting behaviours and home environment. In addition, children were asked about various sedentary and active life-style activities. Variance components for genetic and environmental factors were estimated by using biometric structural equation modelling techniques.

Results: The prevalence of LBP at least once a month was 15.7%, and at least once a week was 6.7%. There was small difference in pairwise similarity of LBP between monozygotic and dizygotic pairs, suggesting little genetic influence. LBP was not associated with either sedentary or active lifestyle activities, but was strongly associated with children’s unsatisfactory perception of the following: home environment (p< 0.001), parenting behaviours (Spearman rho = 0.12, 95% CI 0.06–0.18), relationship with mother (p=0.02) and father (p=0.04). Of the total variance in LBP, 41% (95% CI 34 to 48) could be attributed to shared environmental factors within families; and 59% (52 to 66) to unshared environmental factors.

Conclusion: Genetic factors seem to play a very minor role in LBP in 11-year-old twins. Rather than being related to various aspects of lifestyle activities, childhood LBP is best predicted by children’s perception of home environment and family functioning.

Pedicle screw fixation has become the norm for the surgical correction of adolescent idiopathic scoliosis (AIS), with much biomechanical research into different types of rod screw constructs. The senior authors have experience using a monoaxial screw only construct in the correction of AIS since 2003 and the polyaxial screw only construct since 2005.

We retrospectively reviewed our experience in the first ten patients with AIS using the polyaxial system and compared this against 18 patients who had been corrected using the monoaxial system. Table I shows our results, expressed as mean and ranges or means ± SD for the main thoracic and lumbar curves.

Our early results show that the polyaxial system produces similar correction of both the thoracic and lumbar curves as compared to the monoaxial system in the immediate post-operative period. Though the absolute values for the lumbar curves differ between the two groups the percentage correction shows no statistical difference.

Background: Most reports of sickness absence come either from company records, which are limited to specific workforces, or rely on self-report. Electronic recording of sickness certification in primary care medical records provides an alternative source of information.

Purpose: To investigate the validity of electronic sickness certification records in primary care.

Methods: Analysis included 292 primary care LBP consulters, who returned a questionnaire including self-reported work absence, and consented to medical record review. Sickness certification records for 2001–2 were downloaded. Self-reported sickness absence for the previous 2-weeks was matched with electronic records for the same time period. Records were considered to match if there was no reported absence and no certificate, if there was reported absence > =7 days and a certificate, or if reported absence was < 7 days and no certificate was issued.

Results: Overall, 84% of records matched; 87% of employed consulters and 90% of unemployed consulters. Among the employed, 100% of reports of no absence did not have a certificate, 49% of reported absences > =7 days were matched by a certificate for the same time period and lastly, 80% of reported absences of < 7 days did not have a certificate.

Conclusion: We have demonstrated that people with none or short self-reported work absences do not have sickness certificates in their records, but only a small proportion of people with longer self-reported absences appear to have certificates. Further work will investigate possible reasons for non-matching, these may include non-requirement of a certificate, recall errors or incomplete recording of sickness certificates.

We studied the long term outcome, using the Oswestry Disability Index (ODI), on patients who were managed at our institution between February, 1997, and August, 2004, with a diagnosis of a primary spinal infection, excluding TB or post-operative infection. Patients were identified from databases held within the Departments of Radiology, Orthopaedic Surgery, Neurosurgery and Microbiology. This identified 98 adult patients who fulfilled our inclusion criteria, of who ODIs were calculated on 66, with a mean follow-up of 5 years. There were initially 53 male and 45 female patients with a mean age of 60 years (range 21 0 86) at presentation and symptoms had been present on average for 72 days prior to admission. Back pain was the predominant symptom in 59 and neuropathy in 43. Our figures would suggest a mush higher incidence of primary spinal infection than previously quoted. 75% had significant co-morbidities and 85% of patients under 40 years of age were IV drug users. The causative organisms and their effect were noted. Admission WCC (mean 11.5 ± 8.6) and CRP (mean 128 ± 48) were obtained in the majority of patients (97/98 & 94/98). For those patients who were still available to f/u, the mean ODI was 32 ± 25.

Background: Each year, 7% of the adult population consult their General Practitioner (GP) with low back pain (LBP). Approximately half of these patients still experience disabling pain after three months. Evidence suggests a biopsychosocial approach may be effective at reducing long-term pain and disability. This study aimed to evaluate, for persistent disabling LBP, the effectiveness of an exercise, education and cognitive behavioural therapy intervention compared to usual GP care plus educational material, and to investigate the effect of patient preference.

Method: Design: randomised controlled trial. Patients, aged 18–65yrs, consulting their GP with LBP were recruited. After 3 months those still reporting disabling LBP (≥20mm on 100mm pain visual analogue scale (VAS) and ≥5 Roland and Morris Disability Questionnaire (RMDQ) points) were randomised, having first established preference, to 2 groups. VAS and RMDQ were assessed at 0, 6, and 12-months post-intervention.

Results: 234 patients were randomised; 116 to the intervention. The intervention showed small non-significant effects at reducing pain (3.6mm) and disability (0.6points RMDQ) over one year. Preference showed significant interaction with treatment effect at one-year; patients had better outcomes if they received their preferred treatment.

Conclusion: The above intervention program produces only a modest effect in reducing LBP and disability over a one-year period. These results add to accumulating evidence that interventions for LBP produce, at best, only moderate benefits. The challenge for future research is to evaluate interventions tailored for specific LBP sub-populations. These results suggest that if patients receive treatment which they believe is beneficial their outcome can be optimised.

Aim and method We report the outcomes of 100 consecutive diabetic patients who had been prescribed diabetic footwear for 10 years. A podiatrist and orthotist reviewed them at a dedicated clinic. The study aim was to assess footwear efficacy and prevention of ulcers, re-ulceration and amputations.

Conclusion Protective footwear is essential in maintaining healthy diabetic feet. Amputations were only due to vascular complications. All 56 patients who attended remained intact at 2 years. Of the seven ulcerations at 5 years, three went onto below-knee amputation. At 10 years, there were a further three ulcerations, resulting in one minor black toe and one further BK amputation.

Adherence with follow up including footwear review minimises risk. Re-ulceration at 5 years is associated with risk of amputation. Ten-year mortality is high due to vascular complications.

Summary Continued patient adherence with Orthotic therapy confers benefit and minimised re-ulceration. Follow up by Orthotists is an under-utilised resource.

Charcot neuroarthropathy is a progressive, destructive process occurring in the presence of neuropathy. We report the outcome of neuropathic foot joints presenting to our clinic over a 12 year period.

Methods

Cases were identified from the Diabetic Foot Clinic Register, 1989–2001. We studied patient demographics, clinical presentation, distribution, treatment and outcome.

Results

Twenty-eight episodes of arthropathy occurred in 23 patients. Age at onset ranged from 40 to 79 years. Presentation was acute in 14 and subacute in the others. Sites affected included 23 mid foot, 4 ankle and 1 MTP. Nine feet were ulcerated at presentation, eight had a history of ulcer, nine have no ulcer history. Infection complicated the Charcot process in 15. Mean Hba1c at presentation was 9.3%.

Treatments

Total contact casting 23, 4 “scotch cast” boots and 1 Air-cast walker. Pamidronate was given to 10 patients.

Outcomes

Three patients died. Two had below knee amputations. Casts were required for up to 12 months. Three required orthopaedic foot reconstructions. All ulcers present initially healed.

Conclusion

Charcot arthropathy remains uncommon. In our series treatment was successful in all but two patients in terms of preserved limbs, mobility and freedom from ulceration.