Abstract

Background

BANDAIDE aka Back and Neck Discomfort relief with Altered behaviour, Intelligent Postures, Dynamic movement and Exercises (ISBN - 0995676933) is a concise self-help booklet containing strengthening exercises and illustrated information to enable patients self-manage their back and neck pain. The aim of this preliminary audit was to determine patient opinion on BANDAIDE. Institutional audit approval was obtained – No. 8429.

Background

Free From Pain (aka Fear Reduction, Exercise Early with Food from plants, Rest and relaxation, Organisation and Motivation to decrease Pain from Arthritis and Increase Natural Strength) is a functional rehabilitation programme to combat sarcopenia and musculoskeletal pain in seniors. It is also published as a book (ISBN-0995676941). The aim of this audit was to evaluate the safety and suitability of the exercises and the usefulness of the exercise book.

Aims

To capture the views of various members of the healthcare system with regards to whiplash injuries and in particular, the cumulative effects of whiplash on a patient seeking compensation.

Background

Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered.

Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered.

To assess health care professionals knowledge with regards to urinary symptoms of CES and when treatment should be offered.

A 4-part questionnaire established profession and number of cases seen per week. The participant was asked to rank 15 urinary symptoms, 7 of these symptoms were not related to CES. The participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES.

Primary and Secondary Care

60 questionnaires were complete. Participants had to successfully complete the first three parts of the questionnaire (n = 44). Any who failed to complete section four were excluded from analysis from that part only (n = 41).

A total of 44 questionnaires were analysed. Both doctors and physiotherapists ranked the CES symptoms on average significantly higher than then the non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05).

87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours. 46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours.

These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment.

Purpose of study

A recent audit in our institution showed that 40% of Lumbar spine X-rays ordered by General Practitioners were outside the Royal College of Radiology guidelines. Little in 1998 had commented that GPs requested Lumber Spine X-rays for psychosocial reasons.

Purpose of study

The Royal College of Radiology (RCR) provides guideline criteria to order lumbar spine X-rays for back pain. An audit was undertaken in our hospital to see compliance with this guideline.

Objectives

To assess health care professional's knowledge with regards to the urinary symptoms of CES and when treatment should be offered.

Introduction:

“Spine Class” was organised at Southport Hospitals NHS Trust. The course was awarded 6 CPD (Continuing Professional Development) points. We propose a new method for assessing the effectiveness of educational courses by pre and post testing and participant satisfaction.

Aim: This study aims to quantify pain relief and quality-of-life benefit from a diagnostic SIJ injection.

Methods: 50 consecutive patients were retrospectively recruited with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the SIJ, and no obvious source of pain in the lumbar spine. These were selected for a diagnostic SIJ injection. A structured questionnaire was completed both pre- and post-injection. Median patient age was 63. All patients were injected under fluoroscopic imaging with Triamcinolone 40mgs and 3mls Ropivacaine hydrochloride.

Results: Onset of lower back pain symptoms ranged from 1962 to 2007. 38 patients (76%) had some form of previous non-operative treatment. No patients had previous injection or surgery. 8 patients (16%) were smokers. 17 patients (34%) had a desk based job, 22 patients (44%) had a manual job, 7 patients (14%) had heavy manual jobs. 18 patients (36%) had sustained previous back injury. A visual assessment score was carried out for low back pain and pain in both legs, both pre- and post-injection. Overall, 16 patients (32%) reported no change in their symptoms, 7 (14%) reported worsening, but in 27 (54%) improvement was recorded. When considering the Oswestry Disability Index score, 18% reported no symptom change, 24% worsened and 58% improved.

Conclusion: History and physical examination can enter SIJ syndrome into the differential diagnosis, but cannot make a definitive diagnosis. Fluoroscopically guided diagnostic SIJ injection is the gold standard test for making the diagnosis whilst also conferring substantial pain relieve and quality-of-life benefit.

Conflicts of Interest: None

Source of Funding: None

Introduction: A survey was conducted among the personnel of Southport and Ormskirk Hospitals NHS Trust to determine the prevalence of spinal pain and the factors that could be related.

Materials and Methods: 200 questionnaires were distributed. Participation was voluntary. Details of sex, age, weight, smoking habits, previous accidents, compensation claims, details of work place, personal habits and presence of pain in the Neck, Thoracic spine, Lower Back and limbs were collected.

Results: Completed data was available only from 122 respondents (61%) who comprised of 16 HCAs, 42 Nurses, 5 OTs, 39 Physiotherapists 15 Theatre Practitioners and 5 others. The average age was 39.5 years. 92 (75.4%) had pain in at least one spinal region. 30 (24.6%) had no spinal pain. 35 (28.7%) had pain in the all the three regions of the spine. 83 of the respondents had Lower back followed by 53 having neck pain. 51 had of mid back pain. 15 of the 39 physiotherapists (38.5%) reported that they had no pain in any region of the spine. This contrasted with the Occupational Therapists in whom none of the 5 (0%) reported a pain free spine. There was no correlation between pain and Age, Sex or Weight. Twenty (16.4%) respondents smoked and the average spinal pain among smokers was 8.45 whilst that of non smokers was 5.03. (p< 0.05).

Conclusions: Among the groups tested the physiotherapists seemed to have healthy backs. Our results from a small survey show a clear correlation between smoking and back pain. These results seem to suggest that health promotion to decrease back pain should promote quitting smoking.

Conflicts of Interest: None

Source of Funding: None

We would like to present a rare case report describing a case in which new-onset tonic-clonic seizures occurred following an unintentional durotomy during lumbar discectomy and decompression. Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%. To our knowledge a case of new onset epilepsy has never been reported in the literature. Although dural rupture during surgery and CSF hypovolemia are thought to be the main contributing factors, one can postulate on the effects of anti-psychiatirc medication with epileptogenic properties. Amisulpride and Olanzapine can lower seizure threshold and therefore should be used with caution in patients previously diagnosed with epilepsy. However manufacturers do not state that in cases were the seizure threshold is already lowered by CSF hypotension, new onset epilepsy might be commoner. Finally, strong caution and aggressive post-operative monitoring is advised for patients with CSF hypotension in combination with possible eplieptogenic medication.

Conflict of Interest: None

Source of Funding: None

Introduction: An audit was undertaken to quantify patient satisfaction in the Orthopaedic Outpatient setting.

Materials and Methods: A 16 point questionnaire on a Likert scale of 1 to 5 was used. 216 consecutive questionnaires were distributed to patients attending the elective orthopaedic clinic during a three week period. The questionnaire collected details of sex, age, the grade of the health professional primarily assessing the patient in the clinic, administration of the appointment, welcome by reception staff, waiting room facilities, 7 questions pertaining to the care provided by the health professional primarily assessing the patient, 1 question regarding nurses and 2 regarding the overall service.

Results: Completed data was available only from 178 respondents (82.4%). There were 109 females and 69 males. 13 patients were under 20, 34 between 20 to 39, 61 between 40 to 60 and 70 over 60. 105 patients were seen by the Consultant, 49 by the Registrar, 14 by the Senior House Officer, 8 by a Physio Practitioner and 2 by an Associate Specialist. The mean score for questions 7 to 13 that pertained to the consultation with the health professional showed the following results. Associate Specialist 5.00, SHO 4.74, Consultant 4.70, Physio 4.68 and Registrar 4.63. The differences were not significant (P=0.017).

Conclusions: Our results show that patients are satisfied by being assessed even by Senior House Officers as long as normal NHS work practices are complied with.

Conflicts of Interest: None

Source of Funding: None

Introduction: Recent articles in the MPS Casebook (Cauda equina syndrome, Gardner and Morley) and BMJ (Cauda Equina Syndrome, Lavy) highlighted the potential dangers of Cauda equina syndrome (CES). CES has the highest rates of litigation due to the risk of symptoms not resolving and having a devastating impact on patients. This study aimed to assess clinician knowledge of the urinary symptoms of CES and the timeframe in which treatment should be offered.

Method: A 4 part questionnaire was constructed. The first part established the status and type of health care professional. The second part assesses how many musculoskel-etal patients are seen in an average week. In the third part the participant is asked to rank 15 urinary symptoms; with 1 being the least alarming and 15 being the most alarming. 7 of the symptoms were not related to CES and so should have been ranked in the bottom seven. Lastly, to highlight an issue raise in the BMJ article; the participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES, with the options being within 24 hours; 24–48 hours; and 48 hours to 2 weeks. The questionnaire was distributed to Health Care Professionals in Southport and Ormskirk Hospital.

Results: The questionnaire was completed by 23 participants (12 Doctors and 11 Physiotherapists). 90.91% of Physiotherapists and 10 Doctors (83.3%) managed to complete the questionnaire as specified. An average of 24 patients was seen by each professional (25 patients doctors; 31 patients Physiotherapist). The 7 false CES urinary symptoms were ranked in the bottom 7 in 76.40% of questionnaires (77.92% in Doctors; 81.82% in Physiotherapists). True CES urinary symptoms were ranked in the bottom 7 in 59.63% of cases (66.23% Doctors; 58.44% Physiotherapists). Finally 91.30% of those asked thought Complete CES should be treated within 24 hours (83.33% Doctors; 100% Physiotherapist); 56.52% thought Incomplete CES should be treated within 24 hours (66.67% Doctors; 45.45% Physiotherapists); 30.43% within 24 to 48 hours (8.33% Doctors; 54.55% Physiotherapists) and lastly 13.04% thought Incomplete CES should be treated within 2 weeks (25% Doctors and 0% of Physiotherapists).

Conclusion: The results show that there is a gap in knowledge of all professional with regards to CES urinary symptoms and the optimal timing of treatment. The results showed that Physiotherapists are more likely to recognise True CES than doctors. False symptoms were ranked lower by Physiotherapists than Medical Professionals. These results demonstrate that physiotherapists are better than Doctors at identifying urinary symptoms in CES. Finally the majority of those asked would treat Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical personnel in the symptoms of Cauda Equina Syndrome and also the timing of treatment.

Aim: This study was a sub group analysis of a larger study. The aim was to quantify pain relief and quality-of-life benefit from a single diagnostic SIJ (Sacro-Iliac joint) injection.

Methods: Between August 2008 and February 2009, 56 consecutive patients were retrospectively recruited with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the SIJ, no obvious source of pain in the lumbar spine and no neurological deficit. These were selected for a diagnostic SIJ injection. A structured questionnaire was completed both pre- and post-injection. Median patient age was 63. All patients were injected under fluoroscopic imaging with Triamcinolone 40mgs and 3mls of 0.5% Ropivacaine hydrochloride.

Results: 6 patients were excluded from the study on the basis of incomplete answers. 38 patients (76%) had some form of previous non-operative treatment. No patients had previous injection or surgery. 8 patients (16%) were smokers. 17 patients (34%) had a desk based job, 22 patients (44%) had a manual job, 7 patients (14%) had heavy manual job. 18 patients (36%) had sustained previous back injury including rear ended road traffic accidents. A numerical rating score was carried out for low back pain and pain in the affected and unaffected leg; both pre- and post-injection. In 27 patients (54%) significant improvement was recorded, 16 patients (32%) reported no change in their symptoms, and only 7 (14%) reported worsening. When considering the Oswestry Disability Index score, 58% improved, 18% reported no symptom change, and 24% worsened. The mean pre injection Numerical Rating Score of back pain in patients who had a previous injury to the back was 7.66 and that improved to 5.72 (P = 0.0287).

Discussion: Sacroiliac joint as a potential source of back pain has had less focus following the identification of the disc pathology by Mixter and Barr. The pain from the joint is real and needs to be addressed specifically with injection as a diagnostic measure. Blanket prescription of “low back - core stability exercises” without identification of other potential non red flag causes of back pain should be discouraged. The mechanism of sacroiliac joint syndrome following road traffic accidents occur due to one leg being on the brake pedal stabilizing one half of the pelvis, whilst the opposite hemipelvis twists forward following a rear end collision.

Conclusion: History and physical examination can enter SIJ syndrome into the differential diagnosis, but cannot make a definitive diagnosis. Fluoroscopically guided diagnostic SIJ injection is the gold standard test for making the diagnosis whilst also conferring substantial pain relieve and quality-of-life benefit. This benefit is also seen in back pain following traumatic injuries including rear end motor vehicle collisions.

Multiple treatments of Sacro-iliac joint (SIJ) dysfunction have been adopted by various disciplines that treat low back pain. The aim of this audit is to evaluate the effect of steroids and Local anaesthetic injection (LA) in the management of SIJ dysfunction and to determine the relation between road traffic accident and low back pain (LBP).

We retrospectively reviewed 31 patients who were diagnosed as having SIJ dysfunction. All patients had steroids and LA injection under x-ray control. Based on previous history of road traffic accident patients were divided into RTA and non-RTA group. Through a postal questionnaire the severity of LBP and leg pain (pre and post injection) were assessed using visual analogue scale (VAS). Functional level was evaluated through the Oswestery disability Index (ODI).

All patients showed improvements in LBP and leg pain post injection with mean improvement in VAS of 2.95 (SD 3.0, p-value < .0001) for LBP and mean improvement of 3.3 (SD 3.3, p-value < 0.001) for leg pain. Similarly the ODI showed mean improvement of 15.0 (SD 17.0, p-value < 0.0001). Patients in the RTA group showed greater improvement than the non RTA group, however this did not reach statistical significance.

We conclude that steroids and LA injection is an effective method in management of SIJ dysfunction. Also our study suggests that RTA can be a potential cause of back pain by causing SIJ dysfunction. We accept that our sample size is small and needed to be confirmed through a prospective randomised controlled trial which is currently taking place in our institution.

Sarcoidosis is a multisystem syndrome characterized by the development of non-caseating granulomata. The lesion disrupts the architecture and function of the tissue in which they reside.

Sarcoidosis in and around the spine is very rare affecting less than 1% of patients with the disease. It can affect various parts of the craniospinal axis: intramedullary, intradural, extramedullary, intraspinal epidural spaces and in vertebral bodies. In this report we present a rare case of sarcoidosis in the intervertebral disc causing diagnostic dilemma. To our knowledge this has never been reported before.

Our patient has had aggressive systemic sracoidosis, however the first presentation of the disease was in his spine in the form of intractable low back and leg pain resistant to treatment. X-ray and MRI showed Listhesis at L4/5. Posterior Fusion was performed. Pain became worse and accordingly anterior fusion was attempted, which was aborted because of excessive bleeding. Patient then developed subcutaneous nodules. Biopsy from the nodules showed features of non-caseating granulomatous lesion. In view of the persistence of his symptoms biopsy from L4/5 disc was performed and showed similar histological features. CT chest and abdomen confirmed the diagnosis of sarcoidosis. The patient was commenced on steroids and Methotrexate.

In this report we highlight the approach to diagnosis and management and present a review of the literature. Our main aim is to make the clinicians more aware of this rare condition and raise the index of suspicion, particularly if the first presentation of this multi-system granulomatous disorder is in the spine.

A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.

Aims: To evaluate the functional outcome following internal fixation of distal humerus intra-articular fractures (AO type C) with a minimum follow up of two years. Methods: Design: Retrospective evaluation and clinical review. Setting: Regional trauma centre Patients and Participants: Twenty six consecutive patients with fractures of the distal humerus were treated over a thirty one month period (June 1993 to December 1995). The mean age was 55years (range,18–82). Clinical review of twenty patients at a mean follow up of more than two years (range 19–48 months). Six patients were lost to follow up. Results: Clinical evaluation of twenty patients was carried out. Fourteen patients (70 percent) had an excellent or good outcome, five patients (25 percent) a fair outcome and one patient (5 percent) had a poor result. Three patients (15 percent) underwent a second procedure for symptomatic metalwork. The mean arc of flexion-extension was 112 degrees (range, 85 to 122 degrees). Fifteen patients (75 percent) were able to return to their pre injury level of occupation and activity. Seventeen patients (85 percent) were satisfied with the final outcome. Conclusion: nternal fixation of intra-articular distal humerus fractures is an effective procedure with an excellent/good functional outcome in most patient age groups. Patients have a high level of satisfaction and return to previous level of activity.

Aims: to evaluate the outcome following internal þxation of olecranon fractures using the techniques of tension band wiring and plating with a minimum follow up of two years. Methods:Design: retrospective evaluation and clinical review. Setting: regional trauma centre. Patients and participants: 48 consecutive patients with fractures of the olecranon were treated over a twenty month period (may 1993 to december 1994). 25 fractures were þxed using a tension band wiring technique and 23 underwent plating; the selection of method was based on agreed radiological fracture pattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction. Clinical outcome (broberg and morrey functional rating index). Results: clinical evaluation of 39 patients was carried out. In the tension band wiring group 17 (85 percent) patients had an excellent or good outcome and 11 (55 percent) patients underwent a second procedure for symptomatic metalwork. In the plating group 16 (84 percent) patients had an excellent or good outcome and 2 (11 percent) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result. Conclusion: internal þxation of fractures of the olecranon results in good functional outcome. Fixation with a plate is effective and produces good outcome even though selected for the more complex olecranon fractures. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.

INTRODUCTION: To audit the workload of an Orthopaedic Surgeon sent on deployment to the Middle East. The cases seen and treated are discussed. The audit was to determine the lessons for the future.

DISCUSSION: 86 in patient admissions occurred between 12.01.2002 and 10.04.2002. A break up of speciality was a follows: Orthopaedic 38, Medical 27, General Surgical 16 and Psychiatric 5. A breakdown of the Orthopaedic cases were as follows: Ankle Injury 5, Arthralgia 3, Closed Fracture 4, Elbow Injury 1, Knee Injury 5, Low Back Pain 5, Multiple Soft Tissue Injury 3, Open Injury 3, Sciatica 1, Shoulder Injury 2, Soft Tissue Injury 3, and Stress Fracture 3. The 3 suspected stress fractures and the 2 gun shot wounds required special mention. 31 of 38 Orthopaedic patients were sent back to the UK through the Aeromedical chain. These patients were subclassified according to the requirement of evacuation through the Aeromedical chain. Seventeen patients, though not fit for theatre were able to undertake their own flight back. A trial of sending them back on unaccompanied flights failed. All patients were then evacuated through the Aeromedical chain. On average this meant one medical attendant per 2 patients. If civilian flights were taken this would have meant an extra expenditure of £4,800 (£600 x 8).

Illness behaviour was noted in 10 of the 38 Orthopaedic patients. All these patients were evacuated to the UK. Malingering as tested by the Burns bench test, modified Schobers test, Hoover test and Inappropriate Waddells signs were positive in 4 of these patients whose initial complaint was of low back pain.

CONCLUSION: It is proposed that the category of patients who are unfit for theatre but fit to fly unaccompanied should be recognised. It is also proposed that patients potentially deployable but showing illness behaviour should be discharged from the services earlier as it causes unnecessary expenditure and enforces extra work on other sincere and fit personnel.

This study was designed to determine the point prevalence of musculoskeletal pain among deployed personnel.

150 questionnaires were randomly distributed through the cashier and the mess at RAF Thumrait. 112 questionnaires were returned. The questionnaire, although a general musculoskeletal one, focused mainly on spine pain and also contained the Short Form 36.

107 males and 5 females responded. 85 (75.89%) personnel reported presence of some pain either in their spine and/ or limbs. There was no difference in the report of pain between the various age groups mentioned (p=0.76). There were significant differences among the different occupational branches (p=0.0023). There was no correlation however between spinal pain and lifting (p=0.79), standing (p=0.28), sitting (p=0.98), or running / jumping/ climbing (p=0.77). Though the 22 smokers reported higher pain than non-smokers this did not show statistical significance. There was negative correlation between the VAS report of pain and the Physical Component of Health (p=0.0001) and between stress at work and the Mental Component of Health (p=0.001) and between stress at work and the Mental component of health (p=0.001).

85 (75.9%) of the 112 personnel who had completed the questionnaire had some pain either in the spine or limbs. The lower back was the single anatomical region where pain was reported (n=68,60.7%) most frequently. It is interesting to note that all these personnel were on active duty in the armed forces and considered medically fit to deploy. It only shows to reinforce that low back pain in particular and musculoskeletal pain in general is common and normal and does not always imply disease and disability.

Recent years have seen the popularization of minimally invasive approaches to the spine.

However, the use of the balloon assisted retroperitoneal approach has not been widely described, moreover there has been no direct comparison between this mini-ALIF (anterior lumbar interbody fusion) and the conventional open method in the literature.

Comparison of peri and intra-operative parameters between the rnini-ALIF (using the balloon assisted dissector and Synframe retractor system) and the open midline approach for single and double level anterior lumbar interbody fusions in order to assess the efficacy of this procedure.

An independent retrospective evaluation of 35 patients who underwent single or double level ALIF under the care of the senior author at the University Hospital, Nottingham during the period from 1997 to 2000. The patients were split between those undergoing a mini-ALIF (balloon assisted retroperitoneal dissection) or the conventional approach via a larger midline incision. The groups were matched for age, sex and number of levels. Data was collated from the medical notes with regards to intra-operative blood loss, operative time, intra-operative complications, PCA requirements, time to mobilisation and length of hospital stay.

A statistically significant (p=0. 01) reduction in time to mobilisation (mean 2. 1 days vs 3. 9 days) and operative time (mean 175mins vs 265mins) was found for the single level mini-ALIF. This reflects the greater number of L5/SI fusions in this group. The number of vascular injuries was also greater in the approach to L4/5.

No difference was found between the two groups for double level procedures.

The immediate advantages of a less invasive approach both to the patient and hospital do not appear to be borne out by this study. Cosmesis was not assessed and the long term functional outcome awaits later confirmation.

Objective: A clear definition of cauda equina syndrome (CES) following herniated discs was not available from the literature. Some define CES as a total paralysis of the pelvic viscera1 while others consider any dysfunction as sufficient evidence of CES2. An extensive search of the literature also demonstrated a lack of a disease specific outcome measure for CES. We aimed to classify CES in the above spectrum and validate a new outcome score for CES.

Design and subjects: We present a retrospective study of 38 patients with a minimum of one-year follow up who presented with an acute cauda equina syndrome. We categorized the patients as complete or incomplete and further sub-classified them as acute or chronic. A total paralysis of the pelvic viscera was considered as complete. Presence of only dysfunction of the pelvic viscera was considered as incomplete. If the presenting episode plateaued within 24 hours or less of onset it was classified as acute and if it plateaued later than 24 hours it was considered as chronic.

Outcome measures: The new 17-item disease specific questionnaire was compared with the Oswestry Disability Index, SF36 and Urodynamic studies.

Results and conclusion: Of the patients studied, 44.7% were complete with acute onset, 21.1% were complete with chronic onset, 10.5% were incomplete with acute onset and 23.7% were incomplete with chronic onset. Outcome score matched the spectrum of our suggested classification.

Objective: To determine if a porous, coralline-derived hydroxyapatite block (ProOsteon 500^TM, Interpore, Irvine, CA) is a suitable substitute for tricortical iliac crest autograft in cervical interbody fusion.

Design: A prospective randomised trial with two-year follow-up comparing clinical and radiographic outcomes in patients receiving either iliac crest or hydroxyapatite grafts in cervical interbody fusion.

Subjects: Twenty-nine patients undergoing cervical fusion and anterior plating were randomised to receive either iliac crest (Group I) or hydroxyapatite (Group II) interbody grafts. Fourteen patients (19 grafts) in Group I and twelve patients (18 grafts) in Group II were available for final analysis. Both groups were similar with respect to age, sex, diagnosis and levels fused.

Outcome Measures: The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Post-op and final follow-up radiographs were analysed for graft fragmentation, loss of height, loss of angular alignment and hardware failure to assess structural integrity of the graft. Computed or plain tomography was used to evaluate fusion.

Results: Groups I and II demonstrated improvement in preoperative scores for bodily pain (p=. 016 and. 016 respectively) and physical functioning (p=. 050 and. 016 respectively) at final follow-up. There was no significant difference in SF-36 and Oswestry scores between the two groups. Successful radiographic fusion was similar in both groups (79% in Group I and 76% in Group II). Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (p=. 001). Greater than 2mm of graft height and 3° of segmental lordosis were lost in 55% of hydroxyapatite grafts vs. 11% of autografts (p=. 009). One patient in Group II and none in Group I required revision surgery for graft failure. The high rate of early radiographic failure in the hydroxyapatite grafts prompted suspension of further enrolment in the clinical trial.

Conclusions: ProOsteon 500 coralline hydroxyapatite blocks do not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion.

Objectives: Comparison of peri and intraoperative parameters between mini-ALIF (using balloon assisted dissector and Synframe retractor) and open midline approach for single and double level ALIF.

Methods: Independent, retrospective evaluation of 35 patients split between those undergoing the mini-ALIF or the conventional approach via larger midline incision. Groups matched for age, sex and number of levels. Operations performed at University Hospital, Nottingham between 1997 and 2000.

Outcome measures: Data collated for operative time, intraoperative blood loss, complications, PCA requirements, time to mobilisation and hospital stay.

Results: Statistically significant (p=0.01) reduction in operative time (175 vs 265mins) and time to mobilization (2.1 vs 3.9 days) found for single level mini-ALIF. Complications namely vascular injuries were almost equal in both groups. No difference was found between the two groups for double level procedures.

Conclusion: The immediate advantages of a less invasive approach both to the patient and the hospital do not appear to be borne out by this study. Cosmesis was not assessed and long term functional outcome awaits later review.

Objective: To assess the clinical outcome and return to sport following surgical treatment of spondylolysis in young sporting individuals.

Design: A prospective outcome analysis of consecutive surgically treated cases of lumbar spondylolysis in young sporting individuals.

Subjects: Twenty-two young sports persons (15M: 7F) with a mean age of 20.2 years (range 15–34 years) were surgically treated for radiographically confirmed spondylolysis between 1994 and 1999. Eleven patients were professional footballers and four were professional cricketers. Pre operative assessment included plain X-rays, SPECT imaging with planar bone scan and reverse gantry CT scans. All subjects had pre-operative Oswestry Disability Index (ODI) and SF36 scores recorded. Eighteen patients underwent Buck’s fusion and four patients underwent Scott’s fusion. A graduated exercise regime was commenced at 12 weeks. At two year follow-up nineteen patients had ODI and SF36 scores recorded.

Outcome Measures: The clinical outcome in individual patients supported by statistical analysis of the pre operative and post-operative data was performed using SPSS (ver 10). Return to the sporting activity at the previous level was regarded as a successful outcome.

Results: Eleven patients had bilateral spondylolysis at L5. Twenty patients had positive uptake on SPECT imaging and the remaining two were diagnosed to have lysis on CT scans alone. The average duration of back pain before the patients underwent surgery were 8.4 months (range 3–36 months). The mean lysis defect determined by CT was 3.5 mm (range 1–8 mm). The mean pre-operative and post-operative ODIs were 40.5 and 12.4 respectively (SEpreop = 2.06 and SEpostop = 3.05). The mean scores of physical health component of SF36 improved from 27.1 to 47.8 (SEmean = 1.1 and 1.7 respectively). The mean scores of mental health component of SF36 improved from 39.1 to 55.3 (SEmean = 0.9 and 1.4 respectively) [P < 0.001]. Eighteen patients returned to their previous active sporting career following an average of seven months of rehabilitation (range 4–10 months).

Conclusions: The surgical repair of bilateral spondylolysis with Buck’s fusion in professional sportsmen and women results in a significant improvement in Oswestry Disability scores (P< . 001) and in all domains of SF36 health questionnaire (P< . 001). 90% return to active sport seven months following surgery.

Objective: To study the long term operative and non-operative outcome in patients with diastematomyelia (DM).

Design: A prospectively acquired database of all spinal patients seen jointly by the senior authors (JKW, JLF), was searched for patients with DM. Their notes and the database were then reviewed.

Subjects: Thirty-six patients were identified; twenty-one (58%) had associated scoliosis. There were 60 associated abnormalities in the 36 patients, most common being ten (27%) with leg length inequality. Twelve patients (33%) had no radiological bony abnormality. Twenty-four (66%) had neurosurgery, eleven (31%) untethering of filum alone and eleven (31%) with removal of a spur and closure of the DM as well. Nineteen (53%) underwent some sort of neuraxial shortening scoliosis correction/surgery. Twenty-eight (78%) were deemed to have a normal/independent neurological outcome, seventeen (61%) having neurosurgery and twelve (43%) scoliosis surgery.

Conclusions: Patients with DM have been followed up for many years. Good neurological outcomes can be anticipated in cases with untethering and with scoliosis correction alone. This series raises the question as to whether any unthethering procedure is necessary in these cases when neuraxial shortening is carried out for scoliosis cases.

Advances in laparoscopic technology have popularised minimally invasive approaches to the anterior lumbar spine. The use of the balloon assisted retroperitoneal approach however has not been widely described; moreover there has been no direct comparison between this mini anterior lumbar interbody fusion (ALIF) and the conventional open method in the literature.

Comparison of peri and intra-operative parameters between the mini-ALIF (using the balloon assisted dissector) and the open midline approach for single and double level anterior lumbar interbody fusions in order to assess the efficacy of this procedure.

An independent retrospective evaluation of 35 patients who underwent single or double level ALIF. A single surgeon at the University Hospital, Nottingham, performed the procedures during the period from 1997 to 2000. The patients were split between those undergoing a mini-ALIF (balloon assisted retroperitoneal dissection) and the conventional approach via a larger midline incision. The groups were matched for age, sex and number of levels. Data was collated from the medical notes with regards to intra-operative blood loss, operative time, intra-operative complications, Patient Controlled Analgesic (PCA) requirements, time to mobilisation and length of hospital stay.

A statistically significant reduction in operative time (mean 178mins Vs 255mins) and time to mobilisation (mean 2.2 days Vs 3.7days) was found for the single level mini-ALIF. No other significant difference was detected for the other criteria between the two groups for either single or double level procedures. Complications in the form of vascular injuries were almost equal in both groups.

Although operating time was significantly shortened using the balloon-assisted dissector other perioperative parameters were not. The question of cosmesis of the surgical scar was not explored in this study, this may have been more favorable in the mini-ALIF group but given the above results one must question whether the added expense of this innovative device is justified when there was no detected difference in all other measured criteria.

To determine the current practice and to review the literature regarding administration of high dose Methylprednisolone for acute spinal cord injury (SCI).

Administration of high dose Methylprednisolone for Acute Spinal Cord Injury has been widely practised following the publication of the three National Acute Spinal Cord Injury Studies (NASCIS). NASCIS recommends a bolus intravenous dose of 30mg/kg of Methylprednisolone in 15 minutes, followed by a 45 min pause and then followed by a maintenance dose of 5.4 mg / kg / hr for 23 hours. This regime has been recommended by the Advanced Trauma Life Support. The Cochrane reviews also extol the three NASCIS randomised controlled trials. The mechanism of neuroprotection by Methylprednisolone is based on its inhibition of lipid peroxidation. Three hundred questionnaires were sent to Consultants practising Spinal surgery, Neurosurgery and Accident & Emergency to determine the popular thought regarding the use of Methylprednisolone for Acute SCI. A thorough review of current medical literature was also performed. The literature search showed contradictory evidence regarding the use of high dose Methylprednisolone.

The current popular thought, the diversity of responses between the three groups, the results of the 3 NASCIS trials and a recent review of literature is presented.