FORECAST is a prospective longitudinal cohort study exploring mechanism-based prognostic factors for pain persistence in sciatica. Here, we share an update on this largest deeply-phenotyped primary care sciatica cohort. Our cohort includes 180 people with sciatica (score >4 on Stynes’ Sum Score), aged 18–85, within 3 months of symptom onset. Psychosocial factors, self-reported sensory profiling, clinical examination, quantitative sensory testing (QST), biological samples (blood and skin samples), and Magnetic Resonance Neurography of lumbar nerve roots were collected at baseline. Pain persistence was determined at three and twelve months with the Sciatica Bothersomeness Index (SBI) and a numeric pain rating scale (NRS) as primary outcomes. Recruitment nears completion, with 160 participants enrolled to date. 127 and 96 participants have completed 3 and 12 months follow-up respectively. Overall, 56% of our cohort are female, with a mean age (SD) of 54.14yrs (16.57). Ethnicity data approximates local populations. SBI at baseline was (median [IQR]) 13[10-17], and interim longitudinal data shows stepwise improvement at 3 and 12 months. Baseline ‘average’ pain intensity was 5.56 (2.15) for leg pain, and 4.14(2.82) for low back pain (LBP). Overall, pain scores decreased at 3 and 12 months, with greater reductions in leg pain than LBP at 12 months. However, around 55–80% and 40–65% of people reported persistent pain at 3 and 12 months respectively.Background
Methods/results
The relationship of degeneration to symptoms has been questioned. MRI detects apparently similar disc degeneration and degenerative changes in subjects both with and without back pain. We aimed to overcome these problems by re-annotating MRIs from asymptomatic and symptomatic groups onto the same grading system. We analysed disc degeneration in pre-existing large MRI datasets. Their MRIs were all originally annotated on different scales. We re-annotated all MRIs independent of their initial grading system, using a verified, rapid automated MRI annotation system (SpineNet) which reported degeneration on the Pfirrmann (1-5) scale, and other degenerative features (herniation, endplate defects, marrow signs, spinal stenosis) as binary present/absent. We compared prevalence of degenerative features between symptomatics and asymptomatics. Pfirrmann degeneration grades in relation to age and spinal level were very similar for the two independent groups of symptomatics over all ages and spinal levels. Severe degenerative changes were significantly more prevalent in discs of symptomatics than asymptomatics in the caudal but not the rostral lumbar discs in subjects < 60 years. We found high co-existence of degenerative features in both populations. Degeneration was minimal in around 30% of symptomatics < 50 years. We confirmed age and disc level are significant in determining imaging differences between asymptomatic and symptomatic populations and should not be ignored. Automated analysis, by rapidly combining and comparing data from existing groups with MRIs and information on LBP, provides a way in which epidemiological and ‘big data’ analysis could be advanced without the expense of collecting new groups.
To evaluate the clinical and cost-effectiveness of a physical and psychological group intervention (BOOST programme) compared to physiotherapy assessment and advice (best practice advice [BPA]) for older adults with neurogenic claudication (NC) which is a debilitating spinal condition. A randomised controlled trial of 438 participants. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data was also collected at 6 months. Other outcomes included Swiss Spinal Stenosis Questionnaire (symptoms), ODI walking item, 6-minute walk test (6MWT) and falls. The analysis was intention-to-treat. We collected the EQ5D and health and social care use to estimate cost-effectiveness. Participants were, on average, 74.9 years old (SD 6.0). There was no significant difference in ODI scores between groups at 12 months (adjusted mean difference (MD): −1.4 [95% Confidence Intervals (CI) −4.03,1.17]), but, at 6 months, ODI scores favoured the BOOST programme (adjusted MD: −3.7 [95% CI −6.27, −1.06]). Symptoms followed a similar pattern. The BOOST programme resulted in greater improvements in walking capacity (6MWT MD 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio 0.6 [95% CI 0.40, 0.98]) compared to BPA at 12 months. Probability that the BOOST programme is cost-effective ranged from 67%–89% across cost-effectiveness thresholds.Purpose and background
Methods and results
The primary aim of this study was to evaluate the performance
and safety of magnetically controlled growth rods in the treatment
of early onset scoliosis. Secondary aims were to evaluate the clinical
outcome, the rate of further surgery, the rate of complications,
and the durability of correction. We undertook an observational prospective cohort study of children
with early onset scoliosis, who were recruited over a one-year period
and followed up for a minimum of two years. Magnetically controlled
rods were introduced in a standardized manner with distractions
performed three-monthly thereafter. Adverse events which were both related
and unrelated to the device were recorded. Ten children, for whom
relevant key data points (such as demographic information, growth
parameters, Cobb angles, and functional outcomes) were available,
were recruited and followed up over the period of the study. There
were five boys and five girls. Their mean age was 6.2 years (2.5
to 10).Aims
Patients and Methods
Combined physical and psychological (CPP) programmes are widely recommended for Chronic Low Back Pain (CLBP) patients, but not often implemented. Patients with longstanding CLBP participating in a two-week CPP programme improve in functional status and quality of life and this is maintained at two-year follow up. One-year follow-up data is available of 955 participants. Evaluation of one-year follow-up outcomes of a large cohort (n=848) compared to previously published results of the first 107 patients.Background
Purpose:
Retrospective study of 8 children treated with vertical expandable prosthetic titanium rib (VEPTR) for correction of early onset spinal scoliotic deformities. 8 children with progressive scoliosis due to a variety of conditions, 6 congenital (2 Goldenhar syndrome, 2 VACTERL syndrome, 2 congenital thoracic abnormalities), 1 spondyloepiphyseal dysplasia, 1 early onset of scoliosis, underwent the index procedure and subsequent lengthening procedures at 6 months intervals (1 patient had 11 lengthening procedures). Mean age was 4 years (2-6 years) and mean follow up 3.8 years (2-6 years). Mean preoperative Cobb angle was 64,8° (51-108) and mean postoperative angle 40° (31-50)STUDY DESIGN
METHODS
Retrospective review of outcome of submuscular rod placement without apical fusion for the treatment of scoliotic deformities in children with severe co morbidities (ASA IV). 6 children with progressive scoliosis (2 severe cerebral palsy, 2 congenital cyanotic heart disease, 1 Worster Drought syndrome, 1 Leigh's disease), underwent a serial and limited exposure of the lower and then the upper end of the spine, and insertion of pedicle screws, hooks and clamps. Two submuscularly rods were connected and distracted. Mean age was 13 years old, the mean preoperatively Cobb angle was 87° and the mean postoperatively Cobb angle was 62°. The mean operation time was 120 min and the peri-operative blood loss was 410 ml. Mean follow up is 15 months.STUDY DESIGN
METHODS
Elastic fibres are constructed of a central core of elastin surrounded by microfibrils that are composed mainly of fibrillin-1 and fibrillin-2. Patients with mutations in the gene encoding fibrillin-1 or fibrillin-2 develop Marfan syndrome or Beals syndrome (congenital contractural arachnodactyly), respectively. Scoliosis is one of the clinical manifestations in these patients, but how a defect in the elastic proteins could lead to a spinal deformity is not clear. On the one hand, the mutations could induce scoliosis via mechanical means as they could lead to alterations in the biomechanics of the elastic fibre system. On the other hand, elastic fibres also bind growth factors such as transforming growth factor β (TGFβ) and bone morphogenic proteins (BMPs), and the mutations could hence change patterns of spinal growth. We have investigated the localisation of elastic proteins in different spinal tissues at different stages of curve development in mouse models and in human tissue obtained during scoliosis surgery.Introduction
Methods
A common question posed by adolescents undergoing corrective scoliosis surgery is, “How much taller will I be after my operation?” This study aims to help answer this question, and quantify the gain in height that might be expected. Retrospective data was collected on 68 consecutive surgeries for adolescent idiopathic scoliosis (AIS). Data collected includes age, gender, height, Cobb angle and curve type (Lenke / King classifications). All cases had AIS and were treated by posterior instrumented fusion. Exclusion criteria were neuromuscular/syndromic conditions, anterior approach or revision surgery. Post-operative X-rays were assessed between 1 week and 1 year after surgery.Introduction
Method
To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence 24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%). Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved.
To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery. Retrospective 37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values. Amount of perioperative blood transfusion, costs 14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case. The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial.
A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use. A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications. Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate. The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes. This study did not require ethics approval and no financial support was received.
Plain radiography has traditionally been used to investigate and monitor patients with adolescent idiopathic scoliosis. The X-ray allows a calculation of the Cobb angle which measures the degree of lateral curvature in the coronal plane. ISIS2 is a surface topography system which has evolved from ISIS, but with much higher precision and speed. It measures the three dimensional shape of the back using structured light and digital photography. This system has the benefit of not requiring any radiation. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane. The aim of this study was to compare this parameter to the Cobb angle measured on plain X-ray. Twelve patients with idiopathic adolescent scoliosis underwent both a standing AP spine X-ray and an ISIS2 scan on multiple occasions. Both scan and X-ray were done within one month of each other. No patient underwent surgery during the study period. The Cobb angle and the degree of lateral asymmetry were calculated. Twelve patients mean age 12.5 years (range 10-16) were investigated using both ISIS2 and X-ray. They had a mean 2.3 (1-5) combined investigations allowing for 30 comparisons. The correlation between the two measurements was r =0.63 (p=0.0002). The Cobb angle measured on ISIS2 was less than that measured by radiograph in 27 out of 30 comparisons. The mean difference between the measurements was mean 6.4° with a standard deviation of 8.2° and 95% confidence interval of 3.3° to 9.4°. In adolescent idiopathic scoliosis, curve severity and rib hump severity are related but measure different aspects of spinal deformity. As expected, these relate closely but not precisely. ISIS2 offers the promise of monitoring scoliosis precisely, without adverse effects from radiation. The small numbers in this series focus on the group of patients with mild to moderate curves at risk of progression. In this group, ISIS2 was able to identify curve stability or progression, without exposing the subjects to radiation.
To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows
The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory.
Orthopaedic
60
Accident and Emergency
32
Other
25
We report our ten year experience of primary haematogenous non-tuberculous spinal infection. Retrospective case note review of 42 patients presented to our institution with primary spinal infection during 1995-2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.Aim
Method
Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9). Overall it was calculated that HIAS had saved a total of 940 in-patient days.
Mean duration of symptoms was 25 days (range 1–202). Mean time from presentation to diagnosis was 19 days (range 0–172). Staphylococcus Aureus was the most common organism. Mean duration of Intravenous antibiotics was 60 days (range 13–240) followed by oral antibiotics for mean duration of 65 days (range 0–161). CRP was more reliable in monitoring the disease over time. At mean follow up of 5.4 years (0.6–10.5) there has been no mortality directly related to the infection. With our management there has been 14% recurrence rate. All re- presenting within the first year after initial presentation (Mean 5.5 Months, range 1–11). HIAS saved a total of 940 in-patient days with a total cost saving of approximately £350,000.00.
Our knowledge of the incidence of scoliosis and scoliosis surgery is based on a few small scale studies. The National Health Service (NHS) in the United Kingdom has long collected data on hospital based activity. We have used a five year English database (1998–2002) of hospital admission statistics to study age-adjusted admission rates for scoliosis (code M41 in the International Classification of Diseases, 10th revision) and for two scoliosis surgery codes (V41 ‘instrumental correction of deformity of spine’ and V42 ‘other correction of deformity of spine’ (the latter includes ‘anterolateral release of spine for correction of deformity’).
Social deprivation – we were able to study this, and admission rates appeared independent of social deprivation. Availability of spine surgeons – this may be an explanation, but not very convincing. Scoliosis surgery is concentrated in 15 centres that do not obviously link with the variations we found. Variation in decision making about referral and/or treatment (by general practitioners, patients or surgeons). This is possible, but cannot be studied using our data. Regional genetic variation. Some of our maps were consistent with concepts of local biological variation, but are not very convincing. Incomplete or inaccurate coding in routine hospital statistics. Cannot be studied using our database alone.
Work supported by Fondation Cotrel
ISIS2 is a surface topography system measuring the three-dimensional shape of the back in scoliosis patients using digital photography with structured light. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane [
An automated system has been developed to measure three-dimensional back shape in scoliosis patients using structured light. The low-cost system uses a digital camera to acquire a photograph of a patient with coloured markers on palpated bony landmarks, illuminated by a pattern of horizontal lines. A user-friendly operator interface controls the lighting and camera and leads the operator through the analysis. The system presents clinical information about the shape of the patient’s deformity on screen and as a printed report. All patient data (both photographs and clinical results) are stored in an integral database. The database can be interrogated to allow successive measurements to be plotted for monitoring the deformity. The system is non-invasive, requiring only a digital photograph to be taken of the patient’s back. Identification of the bony landmarks allows all clinical data to be related to body axes. This reduces the effects of variability in patient stance. Measurement of a patient, including undressing, landmark marking and dressing, can be carried out in approximately 10 minutes. The clinical results presented are based on the old ISIS report. This includes:
transverse sections at 19 levels from vertebra prominens to sacrum. coronal views of the line of spinous processes on the surface of the back and the line estimated to be through the centres of the vertebrae; lateral asymmetry, a parameter analogous to Cobb angle, is calculated from the latter. sagittal views of the line of spinous processes on the surface of the back, including kyphosis and lordosis data. Additionally, a three-dimensional wire-frame plot, a coloured contour plot and a pair of bilateral asymmetry plots give visual impressions of any deformity in the measured back.
The surgery results parallel those reported in other trials. At two years, the treatment costs of the surgery arm were approximately twice those of the rehabilitation arm. The costs of the rehabilitation strategy depend on how many patients opt to have surgery after rehabilitation (22% in this trial). This is a comparison of treatment strategies: there was no clinical or statistical difference in outcome between the strategy of spinal fusion and rehabilitation.
Heart rate variance was highest in the Consultant with the most recent appointment. Heart rate variance in the Trainee was the lowest. The highest heart rate was achieved when scrubbed supervising the surgical trainee. The surgeons with the highest deformity work load had the lowest intra-operative heart rate
Scoliosis is a disease characterised by vertebral rotation, lateral curvature and changes in sagittal profile. The role of mechanical forces in producing this deformity is not clear. It is thought that abnormal loading deforms the disc, which becomes permanently wedged. Modelling and in vitro studies suggest that such deformations should increase intradiscal pressure. Intradiscal pressure has been measured previously in a variety of clinical environments. The aim of this study is to measure pressure profiles across scoliotic discs to provide further information on the role of mechanical forces in scoliosis. Pressure readings were obtained in consented patients with ethical approval using a needle-mounted sterilised pressure transducer (Gaeltec, Dunvegan, Isle of Skye) calibrated as described previously. The transducer needle was introduced into the disc of an anaesthetised patient during routine anterior scoliosis surgery and pressure profiles measured. Signals were collected, amplified and analysed using Power-lab and a laptop computer. Pressure profiles across 10 human scoliotic discs from 3 patients have been measured to date. Pressures varied from 0.1 to 1.2 MPa. Annular pressures showed high pressure, non-isotropic regions on the concave but not convex side of these discs. Nuclear pressures recorded from the discs of these scoliotic patients were higher than those recorded previously in non-scoliotic recumbent individuals.
Glycosaminoglycans (GAGs) govern the osmotic environment of cartilaginous tissues and hence determine their ability to resist the large compressive forces encountered during normal activity. In degeneration GAGs are lost and there is now much interest in biological repair processes where cells from cartilaginous tissues synthesise replacement GAGs and other matrix components in situ. In addition, cells can be grown in tissue engineered constructs. Unfortunately, GAG synthesis is slow. The aim of this study was to determine whether GAG accumulation could be hastened by increasing cell density in a construct using articular cartilage and intervertebral disc cells cultured in alginate beads. Bovine chondrocytes and intervertebral disc cells were placed in alginate bead suspension at varying cell densities. GAG synthesis rates, total GAG accumulation and lactate production rates were determined by standard methods. The cell viability profile across intact beads was determined using fluorescent probes. Increasing cell density causes a reduction in lactate production and sulphate incorporation per million live cells. At greater than 20 million cells per ml, cell death is increased compared with lower densities. GAG produced per bead is not increased in proportion to increasing cell density. These results show that there is a limit to the rate at which matrix per volume of tissue can be produced and accumulated. At high cell densities cellular activity is limited by toxicity arising from low pH and hypoxia.
Instability may present at a different level after successful stabilisation of an unstable segment in apparently isolated injuries of the cervical spine. It can give rise to progressive deformity or symptoms which require further treatment. We performed one or more operations for unstable cervical spinal injuries on 121 patients over a period of 90 months. Of these, five were identified as having instability due to an initially unrecognised fracture-subluxation at a different level. We present the details of these five patients and discuss the problems associated with their diagnosis and treatment.
Mechanical abnormalities of the patellofemoral joint are among the many causes that have been suggested for adolescent knee pain. This study seeks to identify these factors. Measurements of joint mobility and lower limb morphology were made on 446 pupils at a comprehensive school, 136 of whom had suffered knee pain in the previous year. The pupils with symptoms enjoyed sporting activities significantly more than their symptom-free contemporaries. Joint mobility, the Q-angle, genu valgum and anteversion of the femoral neck were not significantly different between those pupils with and those without anterior knee pain. Data on lower limb morphology of normal adolescents are presented. Examination of 52 hospital outpatients aged 13 to 36 years with anterior knee pain produced results comparable with those for the pupils. It is concluded that chronic overloading, rather than faulty mechanics, is the dominant factor in the genesis of anterior knee pain in adolescent patients.