Study Design: Prospective cohort study.

Objectives: To evaluate outcomes for back pain following primary single level spinal decompression for nerve root pain.

Subjects: All patients were managed in a single spinal unit with two spinal surgeons following the same management protocol. Any patient undergoing spinal fusion was excluded. Over a five-year period there were 217 patients, with a mean age of 39 years (15 to 78 years). The male to female ratio was 1:1. All had specific single level nerve root pain and definite nerve root compromise confirmed on MRI.

Outcome Measures: All patients were assessed preoperatively and followed at 3, 6, 12 and 24 months using a standard back pain questionnaire including visual analogue scores for leg and back pain, a pain diagram, Oswestry disability index (ODI), Zung depression index and somatisation scores.

Results: We report a statistically significant improvement in back pain post-operatively with 68.6% of patients improving their score (p < 0.001 sign test) with 19.5% reporting complete relief. This improvement was sustained over the follow-up period. Post-operative improvements in back pain correlated well with post surgical reduction in leg pain score, and ODI. Patients with increased back pain scores (> 5) at presentation, were more likely to report an improvement. In this group 80.5% reported a significant reduction in their back pain following surgery. No correlation could be identified between back pain scores and somatisation and Zung depression indices, age, gender or employment status.

Conclusions: These results are contrary to other reported series and suggest the prognosis for back pain following primary single level spinal decompression may be better than anticipated.

Study Design: A retrospective cross sectional cohort study of degeneration of the lumbar spine, using pre- and post-discography MRI scans of 28 patients, as compared to two consecutive MRI scans of an age and sex matched control group of 32 patients.

Objective: To determine whether injection of steroid into a lumbar intervertebral disc causes degeneration, as assessed by magnetic resonance imaging (MRI).

Methods: Twenty-eight patients with chronic discogenic low back pain were selected. Each had been investigated with an MRI, discography (with intradiscal injection of methylprednisolone), and a post-discography MRI scan. A randomly selected control group of thirty-two age and sex matched patients, having been examined on two occasions with MRI, was established. Two interpreters blinded to the patient groups assessed the degree of lumbar disc degeneration on the MRI scans on two separate occasions, using the Pfirrmann grading system.

Results: Kappa values proved interpretation consistency as compared with the published Pfirrmann paper. Variables of age and sex in the two groups showed no true variation in whether the discs improved, stayed the same or degenerated. The difference in the proportions for those with and without the injection gave a test statistic of 11.92 (p-value=0.002), indicating a discrepancy in the degeneration between those discs with and without an injection.

Conclusion: Previous studies on intradiscal steroid injections have shown variable results. Animal studies have shown that steroid administered intradiscally causes degeneration and primary calcification in discs. Two prospective double blind clinical trials using intradiscal steroids identified no significant benefit or improvement in the clinical outcome. This study indicates that intradiscal steroid injections cause MRI visible disc degeneration. In association with the results of the clinical trials, this study questions the indications for the use of intradiscal steroids in the management of discogenic low back pain.

Study Design: A retrospective study of the clinical outcome of patients with lumbar discogenic pain with Modic changes on MRI prior to intradiscal steroid injection.

Objectives: To determine whether the clinical outcome of patients with discogenic back pain who underwent intradiscal steroid injection could be predicted from MRI Modic changes.

Methods: The pre-operative scans were studied by two senior spinal surgeons. The lumbar vertebral end-plate changes were then classified according to the method described by Modic. The intra- and inter-observer ratings were satisfactory.

Subjects: 40 patients with discogenic back pain were recruited in this study. The mean age was 43.6 years (23 to 72 years). The male to female ratio was 1 to 1.

Outcome Measures: The clinical outcomes at six months post-intradiscal steroid injection were correlated with the Modic changes. The clinical outcomes were assessed using visual analogue scores for back pain as well as Oswestry disability index (ODI). At least a 2-point improvement in visual analogue score and a 20-point improvement in ODI were required to indicate significant symptomatic relief.

Results: We found that in those patients without Modic changes there was improvement of the low back pain in 9% (1/11). In those with Modic I changes there were significant relief in 64% (9/14), moderate relief in 29% (4/14) and no relief in 7% (1/14). In those with Modic II changes there were significant relief in 27% (4/15), moderate relief in 27% (4/15) and no relief in 47% (7/15). There were no cases with Modic III changes.

Conclusions: Previous studies on intradiscal steroid injections have shown variable results. Two prospective double-blind clinical trials, using intradiscal steroids, identified no significant benefit or improvement in the clinical outcome. Our results however suggest that patients with Modic I changes on MRI are most likely to benefit from intradiscal steroid injection in the short term.

Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Less significant complications, including post-operative ileus and pseudo-obstruction are also more common following bilateral replacement.

A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last ten years, examines details of surgery and anaesthesia, pre and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure.

While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors’ hands, and documents the high patient satisfaction from it.

The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk.

Introduction: In order to improve the provision of Spinal Surgery in the United Kingdom, the number of Specialist Spinal Surgeons and Surgeons with an Interest in Spinal Surgery needs to increase by 25% from the existing 175 surgeons. There is an expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery not only to maintain the status quo, with one third of Specialist Spinal Surgeons due to retire in the next three years, but also to provide the needed expansion in numbers.

Methods and results: A postal survey of the 528 SpRs was performed with a response rate fo 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty-nine per cent indicated that they intended to avoid all Spinal Surgery. Thirty-five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only nine (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first two years of training, to 70% in the middle two years, and to 75% in the final two years and post C.C.S.T. fellowships. There should be 24 newly accredited Specialist Spinal Surgeons based on a projection of the 4.3% response intending to become Specialist Spinal Surgeons. This leaves a shortfall of 34 Specialist Spinal Surgeons by 2005.

The survey has revealed three main features of Spinal Surgery which appear to have a negative effect on the attitude of the SpRs to Spinal Surgery and overwhelm the potentially attractive features. These are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to Spinal Surgery during their training.

Conclusion: It is clear from the response of SpRs that there are important misconceptions concerning Spinal Surgery, together with the shortcomings of training and of the provision of services within the NHS. These have to be addressed urgently if the speciality is to become more attractive to them. Areas where positive action can be taken include the modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and above all the need for Spinal Surgeons to be encouraging and enthusiastic about a field of surgery which provides some of the exciting challenges in Orthopaedic Surgery.

The relationship between heterotopic bone formation and the morphological type of osteoarthritis was examined after 43 hip replacements. Of the 43 hips studied, nine were atrophic, 19 were normotrophic, and 15 were hypertrophic. The incidence of heterotopic bone formation in the atrophic type was 11%, in the normotrophic type 32%, and in the hypertrophic type 87%. The difference between each type was statistically significant (p less than 0.001).

Seven hips with protrusio acetabuli which showed complete or partial resolution of the protrusion after replacement with Ring's prosthesis are reported. It is suggested that this prosthesis offers a simple and effective method of treating painful protrusion into the pelvis; it allows healing of the medial wall of the acetabulum while avoiding many of the hazards of other methods of treatment.