Aims. Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa. Results. Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17). Conclusion. Inter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable. Cite this article: Bone Joint J 2023;105-B(9):1007–1012

Introduction and aims. Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre. Method and Materials. Data on 80 patients who had received caudal epidural (n=36), nerve root block (n=28) and facet joint injections (n=16) form August 2010 to October 2011 consented to be in the study. 40 patients in each group completed Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) before and 6 weeks after the procedure and patient satisfaction questionnaire investigating their experience and any complications related to the spinal injection retrospectively. The study included 32 males and 48 females. Mean age 57 years, range 21–88. [Consultant group M:17, F:23 mean age: 55, range 21–81. ASP group M:15, F:25 mean age 59, range 22–88]. Measures of patient satisfaction and outcome were obtained; using 2 tailed independent samples t-test with 95% confidence interval, statistical significance was investigated. Results. Data analysis shows that there are no significant differences (p>0.05) in either overall patient satisfaction or outcomes between patients of the surgeon vs physiotherapists. Patients of the surgeon were found to be more satisfied with the procedure itself (p< 0.05). Conclusion. Physiotherapists are able to provide spinal injections with equal efficacy to spinal surgeons, with no reduction in overall patient outcome. Benefits of this scheme include greater number of spinal injections performed. Therefore, reducing the overall waiting times. Further, multi-centre studies on larger populations are required to investigate injection treatment by physiotherapists

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. Cite this article: Bone Joint J 2024;106-B(3):227–231

Introduction: We believe the information given by a new 2D/3D low dose radiation system is useful to the spinal surgeon. Method: This commercially developed system was evaluated over the past three years. We evaluated 150 patients, with normal controls, using two prototypes. We compared it with a CT scan for accuracy in 2D and 3D reconstruction and for radiation doses. Results: We found various advantages of this system over CT scanning:. Reductions in radiation exposure of x8 to x10 fold in 2D, and x800 to x1000 in 3D. It gives data from standing imaging compared with supine in a CT scanner. It allows imaging of the skeleton from head to foot, which in CT imaging demands excessive radiation. It allows surface reconstruction from head to foot. It can be used with a force plate to indicate gravity forces. It, uniquely, can give a view of the skeleton from the top. It can measure thoracic cage volume. It can assess the effects of bracing. When combined with other non-invasive methods of measurement, can help to define operative procedures. Overall it provides a new approach to assessing spinal deformity both in the horizontal plane and in volumetric measurement. Conclusion: his innovative method is clearly a help for both patients and surgeons

Aims

The aim of this study was a quantitative analysis of a surgeon’s learning curve for scoliosis surgery and the relationship between the surgeon’s experience and post-operative outcomes, which has not been previously well described.

Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Cite this article: Bone Joint Res 2023;12(6):372–374.

The June 2024 Spine Roundup. 360. looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following posterior spinal fusion for adolescent idiopathic scoliosis; Characterizing negative online reviews of spine surgeons; Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness; Nutritional supplementation and wound healing: a randomized controlled trial

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442–1448

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Pseudoarthrosis after spinal fusion is an important complication leading to revision spine surgeries. Iliac Crest Bone Graft is considered the gold standard, but with limited availability and associated co-morbidities, spine surgeons often utilize alternative bone grafts. Determine the non-inferiority of a novel submicron-sized needle-shaped surface biphasic calcium phosphate (BCP<µm) as compared to autograft in instrumented posterolateral spinal fusion. Adult patients indicated for instrumented posterolateral spinal fusion of one to six levels from T10-S2 were enrolled at five participating centers. After instrumentation and preparation of the bone bed, the randomized allocation side of the graft type was disclosed. One side was grafted with 10cc of autograft per level containing a minimum of 50% iliac crest bone. The other side was grafted with 10cc of BCP<µm granules standalone (without autograft or bone marrow aspirate). In total, 71 levels were treated. Prospective follow-up included adverse events, Oswestry Disability Index (ODI), and a fine-cut Computerized Tomography (CT) at one year. Fusion was systematically scored as fused or not fused per level per side by two spine surgeons blinded for the procedure. The first fifty patients enrolled are included in this analysis (mean age: 57 years; 60% female and 40% male). The diagnoses included deformity (56%), structural instability (28%), and instability from decompression (20%). The fusion rate determined by CT for BCP<μm was 76.1%, which compared favorably to the autograft fusion rate of 43.7%. Statistical analysis through binomial modeling showed that the odds of fusion of BCP<μm was 2.54 times higher than that of autograft. 14% of patients experienced a procedure or possible device-related severe adverse event and there were four reoperations. Oswestry Disability Index (ODI) score decreased from a mean of 46.0 (±15.0) to a mean of 31.7 (±16.9), and 52.4% of patients improved with at least 15-point decrease. This data, aiming to determine non-inferiority of standalone BCP<μm as compared to autograft for posterior spinal fusions, is promising. Ongoing studies to increase the power of the statistics with more patients are forthcoming

INTRODUCTION. The correct placement of pedicle screws is a major part of spine fusion and it requires experienced trained spinal surgeons. In the era of European Working Time Directive (EWTD), surgical trainees have less opportunity to acquire skills. Josh Kauffman (Author of The First 20 Hours) examined the K. Anders-Ericsson study that 10,000 hours is required to be an expert. He suggests you can be good at anything in 20 hours following 5 methods. This study was done to show the use of accelerated learning in trainees to achieve competency and confidence on the insertion of pedicle screws. METHODS. Data was collected using 3 experienced spine surgeons, 8 trainees and 1 novice (control) on the cadaveric insertion of pedicle screws over a 4 day didactic lecture in the cadaver lab. Each candidate had 2 cadavers and 156 screw placements over 4 hour shifts. Data was collected for time of pedicle screw insertion for each level on the left and right side. A pre-course and post-course questionnaire (Likert scale) was conducted. RESULTS. There were 8 candidates (surgeons) involved. 1 spinal SpR, 6 spine fellows and 1 junior consultant. A physiotherapist was the control novice. The surgeons and the control got significantly faster over time. The control made significantly more errors than the surgeons. Surgeons were significantly faster by the end (p value < 0.05). The control got faster over time and by the end, was no longer significantly slower than the surgeon when they first started. CONCLUSION. Pedicle screw insertion can cause significant morbidity, which includes paralysis. As a trainee, this is not an easy skill to acquire or practice. This focused pedicle screw course shows that a junior spinal surgeon can achieve improved competency and confidence in 20 hours but furthermore a complete novice can learn to insert pedicle screws and reach a level of competence almost at the level of the trainee in 20 hours as well

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568–572

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

Aims. The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. Methods. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy. Results. A total of 1,123 pedicle screws were implanted: 1,001 screws (89%) were placed robotically, 63 (6%) were converted from robotic placement to a freehand technique, and 59 (5%) were planned to be implanted freehand. Of the robotically placed screws, 942 screws (94%) were determined to be Gertzbein and Robbins grade A with median deviation of 0.8 mm (interquartile range 0.4 to 1.6). Skive events were noted with 20 pedicle screws (1.8%). No adverse clinical sequelae were noted in the 90-day follow-up. The mean fluoroscopic exposure per screw was 4.9 seconds (SD 3.8). Conclusion. RNA is highly accurate and reliable, with a low rate of abandonment once mastered. No adverse clinical sequelae occurred after implanting a large series of pedicle screws using the latest generation of RNA. Understanding of patient-specific anatomical features and the real-time intraoperative identification of risk factors for suboptimal screw placement have the potential to improve accuracy further. Cite this article: Bone Joint J 2023;105-B(5):543–550

Aims. Pelvic incidence (PI) is a position-independent spinopelvic parameter traditionally used by spinal surgeons to determine spinal alignment. Its relevance to the arthroplasty surgeon in assessing patient risk for total hip arthroplasty (THA) instability preoperatively is unclear. This study was undertaken to investigate the significance of PI relative to other spinopelvic parameter risk factors for instability to help guide its clinical application. Methods. Retrospective analysis was performed of a multicentre THA database of 9,414 patients with preoperative imaging (dynamic spinopelvic radiographs and pelvic CT scans). Several spinopelvic parameter measurements were made by engineers using advanced software including sacral slope (SS), standing anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), lumbar lordosis (LL), and PI. Lumbar flexion (LF) was determined by change in LL between standing and flexed-seated lateral radiographs. Abnormal pelvic mobility was defined as ∆SPT ≥ 20° between standing and flexed-forward positions. Sagittal spinal deformity (SSD) was defined as PI-LL mismatch > 10°. Results. PI showed a positive correlation with parameters of SS, SPT, and LL (r-value range 0.468 to 0.661). Patients with a higher PI value showed higher degrees of standing LL, likely as a compensatory measure to maintain sagittal spine balance. There was a positive correlation between LL and LF such that patients with less standing LL had decreased LF (r = 0.49). Similarly, there was a positive correlation between increased SSD and decreased LF (r = 0.54). PI in isolation did not show any significant correlation with lumbar (r = 0.04) or pelvic mobility (r = 0.02). The majority of patients (range 89.4% to 94.2%) had normal lumbar and pelvic mobility regardless of the PI value. Conclusion. The PI value alone is not indicative of either spinal or pelvic mobility, and thus in isolation may not be a risk factor for THA instability. Patients with SSD had higher rates of spinopelvic stiffness, which may be the mechanism by which PI relates to THA instability risk, but further clinical studies are required. Cite this article: Bone Joint J 2022;104-B(3):352–358

Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for decision making, the merit of predictable outcome with THA first, leg weakness as an indication for spine surgery, the concern of THA position with spinal deformity, and the urgency of myelopathy. Conclusion. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial in certain clinical scenarios, even for experienced hip and spine surgeons. Additional outcome studies of these patients are necessary for appropriate decision making

Abstract. Purpose. Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This study aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration. Materials and methods. The grading was developed as four grades: normal rib head (RH) position—Grade 0, subluxed ext-racanal RH position—Grade 1, RH at pedicle—Grade 2, intracanal RH—Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)—Grade 3A, into the middle third—Grade 3B and into the distal third—Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic. Results. There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7–0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9–1.0) and 0.9 (95% CI 0.9–1.0) for the two readers. Conclusion. The novel CT-based classification quantifies rib head penetration which aids in management planning

The minimisation of errors incurred during the learning process is thought to enhance motor learning and improve performance under pressure or in multitasking situations. If this is proven in surgical skills learning, it has the potential to enhance the delivery of surgical education. We aimed to compare errorless and errorful learning using the high-speed burr. Medical students (n=30) were recruited and allocated randomly to an errorless or errorful group. The errorless learning group progressively learnt tasks from easy to difficult on cedar boards simulating bone. The errorful learning group also progressed through the same tasks but not in order of difficulty. Transfer tasks assessed students’ performance of cervical laminoplasty on saw bone models to assess their level of learning from previous stages. During transfer task 2, students completed the procedure under time pressure and in the presence of distractors, in order to simulate real-life stressors in theatre. Accuracy, precision and safety of the procedure were scored by expert opinions from spine surgeons blinded to the grouping of the participants. Both errorless and errorful learners demonstrated improvements in performance with increasing amounts of practice (demonstrated by the decreased time taken for the task as well as improvement in accuracy of the cuts (depth, width and smoothness). The performance of both groups was not impaired by the incorporation of a secondary task which required participants to multitask. No statistically significant difference in performance was noted between the two groups. In contrast to previous research, there was no significant difference between errorless or errorful learning to develop skills with a high-speed, side-cutting burr. In both groups, practical learning during the session has led to improvement in overall performance with the burr relevant to cervical laminoplasty

Background. Scoliosis is described as a lateral spinal curvature exceeding ten degrees on radiograph with vertebral rotation. Approximately 80% of scoliosis presentations are adolescent idiopathic scoliosis (AIS). Current management for AIS in the UK occurs in Surgeon or Paediatrician-led clinics and can be conservative or surgical. The musculoskeletal assessment and triage of AIS appears well-suited to an advanced physiotherapist practitioner (APP) skill set. The aim of this service evaluation was to scope, develop, implement and evaluate a four-month pilot of an APP-led AIS triage pathway. Method and Results. Spinal Consultant deformity and scoliosis clinics were scoped and observed. Clinic inclusion criteria and a patient assessment form was developed. An APP AIS clinic was set up beside a consultant led clinic. All patients assessed were discussed with a spinal surgeon. Consultant and APP agreement (% of total), waiting times, surgical conversion, and patient satisfaction were reviewed. A clinical competency package was developed for training and development of APPs. A total of 49 patients were seen (20 sessions). Waiting list reduced from 10 weeks to 6 weeks. 45%(n=22) of new patients seen were diagnosed with AIS, 27% (n=6) were directly listed for surgery. Consultant/ APP percentage agreement was high for Cobb angle measurement (82%), management plans (90%), and further diagnostic requests (94%). There were no adverse events and high patient satisfaction levels (n=20), (100% Very satisfied or satisfied) were reported. Conclusion. APP-led AIS clinics can provide similar levels of management and assessment as Spinal Consultants with improved waiting times and high levels of satisfaction. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19

Neurological complications in oncological and degenerative spine surgery represent one of the most feared risks of these procedures. Multimodal intraoperative neurophysiological monitoring (IONM) mainly uses methods to detect changes in the patient's neurological status in a timely manner, thus allowing actions that can reverse neurological deficits before they become irreversible. The utopian goal of spinal surgery is the absence of neurological complications while the realistic goal is to optimize the responses to changes in neuromonitoring such that permanent deficits occur less frequently as possible. In 2014, an algorithm was proposed in response to changes in neuromonitoring for deformity corrections in spinal surgery. There are several studies that confirm the positive impact that a checklist has on care. The proposed checklist has been specifically designed for interventions on stable columns which is significantly different from oncological and degenerative surgery. The goal of this project is to provide a checklist for oncological and degenerative spine surgery to improve the quality of care and minimize the risk of neurological deficit through the optimization of clinical decision-making during periods of intraoperative stress or uncertainty. After a literature review on risk factors and recommendations for responding to IONM changes, 3 surveys were administered to 8 surgeons with experience in oncological and degenerative spine surgery from 5 hospitals in Italy. In addition, anesthesiologists, intraoperative neuro-monitoring teams, operating room nurses participated. The members participated in the optimization and final drafting of the checklist. The authors reassessed and modified the checklist during 3 meetings over 9 months, including a clinical validation period using a modified Delphi process. A checklist containing 28 items to be considered in responding to the changes of the IONM was created. The checklist was submitted for inclusion in the new recommendations of the Italian Society of Clinical Neurophysiology (SINC) for intraoperative neurophysiological monitoring. The final checklist represents the consensus of a group of experienced spine surgeons. The checklist includes the most important and high-performance items to consider when responding to IONM changes in patients with an unstable spine. The implementation of this checklist has the potential to improve surgical outcomes and patient safety in the field of spinal surgery

Lumbar fusion surgery is an established procedure for the treatment of several spinal pathologies. Despite numerous techniques and existing devices, common surgical trends in lumbar fusion surgery are scarcely investigated. The purpose of this Canada-based study was to provide a descriptive portrait of current surgeons’ practice and implant preferences in lumbar fusion surgery while comparing findings to similar investigations performed in the United Kingdom. Canadian Spine Society (CSS) members were sampled using an online questionnaire which was based on previous investigations performed in the United Kingdom. Fifteen questions addressed the various aspects of surgeons’ practice: fusion techniques, implant preferences, and bone grafting procedures. Responses were analyzed by means of descriptive statistics. Of 139 eligible CSS members, 41 spinal surgeons completed the survey (29.5%). The most common fusion approach was via transforaminal lumber interbody fusion (TLIF) with 87.8% performing at least one procedure in the previous year. In keeping with this, 24 surgeons (58.5%) had performed 11 to 50 cases in that time frame. Eighty-six percent had performed no lumbar artificial disc replacements over their last year of practice. There was clear consistency on the relevance of a patient specific management (73.2%) on the preferred fusion approach. The most preferred method was pedicle screw fixation (78%). The use of stand-alone cages was not supported by any respondents. With regards to the cage material, titanium cages were the most used (41.5%). Published clinical outcome data was the most important variable in dictating implant choice (87.8%). Cage thickness was considered the most important aspect of cage geometry and hyperlordotic cages were preferred at the lower lumbar levels. Autograft bone graft was most commonly preferred (61.0%). Amongst the synthetic options, DBX/DBM graft (64.1%) in injectable paste form (47.5%) was preferred. In conclusion, findings from this study are in partial agreement with previous work from the United Kingdom, but highlight the variance of practice within Canada and the need for large-scale clinical studies aimed to set specific guidelines for certain pathologies or patient categories

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

Introduction:. Most of the published papers on AI based diagnosis have focused on the algorithm's diagnostic performance in a ‘binary’ setting (i.e. disease vs no disease). However, no study evaluated the actual value for the clinicians of an AI based approach in diagnostic. Detection of Traumatic thoracolumbar (TL) fractures is challenging on planar radiographs, resulting in significant rates of missed diagnoses (30-60%), thus constituting a field in which a performance improvement is needed. Aim of this study is therefore to evaluate the value provided by AI generated saliency maps (SM), i.e. the maps that highlight the AI identified region of interests. Methods:. An AI model aimed at identifying TL fractures on plain radiographs was trained and tested on 567 single vertebrae images. Three expert spine surgeons established the Ground Truth (GT) using CT and MRI to confirm the presence of the fracture. From the test set, 12 cases (6 with a GT of fracture and 6 with a GT of no fracture, associated with varying levels of algorithm confidence) were selected and the corresponding SMs were generated and shown to 7 independent evaluators with different grade of experience; the evaluators were requested to: (1) identify the presence or absence of a fracture before and after the saliency map was shown; (2) grade, with a score from 1 (low) to 6 (high) the pertinency (correlation between the map and the human diagnosis), and the utility (the perceived utility in confirming or not the initial diagnosis) of the SM. Furthermore, the usefulness of the SM was evaluated through the rate of correct change in diagnosis after the maps had been shown. Finally, the obtained scores were correlated with the algorithm confidence for the specific case. Results:. Of the selected maps, 8 had an agreement between the AI diagnosis and the GT, while in 4 the diagnosis was discordant (67% accuracy). The pertinency of the map was found higher when the AI diagnosis was the same as the GT and the human diagnosis (respectively p-value = .021 and <.000). A positive and significant correlation between the AI confidence score and the perceived utility (Spearman: 27%, p-value=.0-27) was found. Furthermore, evaluator with experience < 5 year found the maps more useful than the experts (z-score=2.004; p-value=.0455). Among the 84 evaluation we found 12 diagnostic errors in respect to the GT, 6 (50%) of which were reverted after the saliency map evaluation (z statistic = 1.25 and p-value = .21). Discussion:. The perceived utility of AI generated SM correlate with the model confidence in the diagnosis. This highlights the fact that to be considered helpful, the AI must provide not only the diagnosis but also the case specific confidence. Furthermore, the perceived utility was higher among less experienced users, but overall, the SM were useful in improving the human diagnostic accuracy. Therefore, in this setting, the AI enhanced approach provides value in improving the human performance

There is an inherent risk of iatrogenic new neurological deficit (NND) arising at the spinal cord, cauda equina and nerve root during spinal surgery. Intraoperative neurophysiological monitoring (IONM) can be employed to preserve spinal cord function during spinal surgery. IONM techniques include somatosensory and motor evoked potentials, amongst others. A Canadian survey of 95 spinal surgeons showed that 62.1% used IONM and a similar survey in France of 117 spinal surgeons showed that only 36% used IONM. Unavailability was a common reason for its disuse. Current literature by the British Society of Clinical Neurophysiology has outlined the importance of IONM in preventing NND and the need for the implementation of guidelines for IONM. The lack of an established guideline has resulted in a varied approach in the use of IONM in England. There has been no previous attempt to ascertain the current use of IONM in England. Our study is aimed at assessing the variability of the use of IONM in England as well as identifying the rationale amongst surgeons that dictate their use of IONM. We are in the process of investigating the indications of use of IONM for cervical and lumbar spine procedures in 252 spinal surgeons from 33 hospitals with spinal services. Our survey will illustrate the current use of IONM in spinal surgery in England. It will highlight some of the reasons for the variability of use of IONM and identify factors that can contribute to a more standardised use of IONM in spinal surgery

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research. Cite this article: Bone Joint J 2019;101-B:808–816

Abstract. In the pediatric population, scoliosis is classified into congenital, syndromic, idiopathic, and neuromuscular in aetiology. Syndromic scoliosis represents a wide range of systemic anomalies associated with scoliosis. The primary challenge for a clinician is to think beyond the scoliotic curve, as the underlying pathology is multisystemic. The aim of this review is to identify the systemic anomalies, associated with syndromic scoliosis. MEDLINE, EMBASE, and CINAHL databases were searched, dating from 1990–2020, relevant to the purpose of our study. Keywords used: “scoliosis”+ “syndrome” + “genetic”. Retrospective, prospective studies were included. Case reports that had fewer than 4 patients were not included. Delineating 60 articles, we found a total of 41 syndromes to be associated with scoliosis. Thoracic region was the most common level of scoliosis curve, being noted in 28 syndromes. Mental retardation, seizures, and ataxia were the commonly noticed CNS anomalies. VSD, ASD, and TGA were the anomalies associated with CVS; Hypotonia, rib and vertebral malformations were the most identified neuromuscular anomalies; pulmonary hypoplasia, renal agenesis, and strabismus were other associations. A multidisciplinary approach, involving spinal surgeons, paediatricians, geneticists, anesthesiologists, and allied health professionals, is vital for the best care of patients with syndromic scoliosis. The location of the scoliotic curve reflects the associated anomalies, as thoracic curvature is more closely linked with cardiac anomalies, while lumbosacral curvature is seen to be often linked with genitourinary anomalies. We hope that this article provides a clear overview of the systemic associations in syndromic scoliosis and thus, facilitates and streamlines the management protocol

Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’ symptoms and signs. Of note ‘bilateral sciatica’ had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed ‘low-risk’ of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. Conclusion. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677–682

Introduction and Objective. Up to 30% of thoracolumbar (TL) fractures are missed in the emergency room. Failure to identify these fractures can result in neurological injuries up to 51% of the casesthis article aimed to clarify the incidence and risk factors of traumatic fractures in China. The China National Fracture Study (CNFS. Obtaining sagittal and anteroposterior radiographs of the TL spine are the first diagnostic step when suspecting a traumatic injury. In most cases, CT and/or MRI are needed to confirm the diagnosis. These are time and resource consuming. Thus, reliably detecting vertebral fractures in simple radiographic projections would have a significant impact. We aim to develop and validate a deep learning tool capable of detecting TL fractures on lateral radiographs of the spine. The clinical implementation of this tool is anticipated to reduce the rate of missed vertebral fractures in emergency rooms. Materials and Methods. We collected sagittal radiographs, CT and MRI scans of the TL spine of 362 patients exhibiting traumatic vertebral fractures. Cases were excluded when CT and/or MRI where not available. The reference standard was set by an expert group of three spine surgeons who conjointly annotated (fracture/no-fracture and AO Classification) the sagittal radiographs of 171 cases. CT and/or MRI were used confirm the presence and type of the fracture in all cases. 302 cropped vertebral images were labelled “fracture” and 328 “no fracture”. After augmentation, this dataset was then used to train, validate, and test deep learning classifiers based on the ResNet18 and VGG16 architectures. To ensure that the model's prediction was based on the correct identification of the fracture zone, an Activation Map analysis was conducted. Results. Vertebras T12 to L2 were the most frequently involved, accounting for 48% of the fractures. Accuracies of 88% and 84% were obtained with ResNet18 and VGG16 respectively. The sensitivity was 89% with both architectures but ResNet18 had a significantly higher specificity (88%) compared to VGG16 (79%). The fracture zone used was precisely identified in 81% of the heatmaps. Conclusions. Our AI model can accurately identify anomalies suggestive of TL vertebral fractures in sagittal radiographs precisely identifying the fracture zone within the vertebral body

Background. Sciatica is common and associated with significant impacts for the individual, health care and society. The SCOPiC randomised controlled trial (RCT) is investigating whether stratified primary care for sciatica is more effective and cost-effective than usual, non-stratified primary care. Stratified care involves subgrouping patients to one of three groups based on a combination of prognostic and clinical indicators. Patients in one of these groups are ‘fast-tracked’ with an MRI scan to spinal specialist opinion. Our aim was to understand the perspectives of clinicians on the acceptability of this ‘fast-track’ pathway. Methods. Qualitative, semi-structured interviews were conducted with general practitioners, spinal specialist physiotherapists and spinal surgeons (n=20 in total). Interviews were fully transcribed, and data were analysed using the constant comparison method. Results. Across all groups, clinicians identified potential added value in ‘fast-tracking’ some sciatica patients in terms of patient reassurance based on MRI scan findings. Whilst spinal physiotherapists felt that most ‘fast track’ patients were appropriate, some spinal physiotherapists and GPs had concerns that patients with symptom durations of less than 6 weeks might be inappropriately fast-tracked since their symptoms may still resolve without the need for invasive treatments. Spinal surgeons felt it was acceptable for patients with short symptom durations to be ‘fast-tracked’, but to provide early reassurance rather than direct treatment. Conclusion. Whilst clinicians saw added value in a group of sciatica patients being ‘fast-tracked’ to specialist opinion, there was some reservation about moving away from the usual stepped care, ‘wait and see’ approach for patients with short symptom duration. Conflicts of interest statement. No conflicts of interest. Sources of funding. This study is funded by the National Institute for Health Research Health Technology Assessment Programme (NIHR HTA project number 12/201/09) and will be published in full in Health Technology Assessment. Funding support is also received from an NIHR Research Professorship for Nadine Foster (NIHR-RP-011-015), who is an NIHR Senior Investigator, and a HEFCE Senior Clinical Lecturer award for Kika Konstantinou. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health and Social Care. The study was approved by the NRES Committee West Midlands – Solihull, 17/03/2015, ref: 15/WM/0078. Trial registration: ISRCTN75449581

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains. This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure. To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined. Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective. In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective

Traditionally, spinal surgeons placed radiographs on viewing boxes in a manner (PA) to replicate the view they would have at surgery. The introduction of digital Picture Archiving and Communications System (PACS) appears to have had marked impact upon this convention. Some Units have the ability to lock digital radiographs such that they are always viewed in the same manner and cannot be reversed. Following ‘two near misses’ we carried out a survey to confirm the previous practice with radiographs; to ascertain the current practice with PACS and to find out whether the variation in practice could lead to clinical mishaps and harm to patients. Questionnaires were completed by practicing spinal surgeons. Previous and current practice of viewing radiographs. Either actual or potential wrong side surgery. Opinions as to whether a single convention was important were recorded. 78 % Spine surgeons used to flip radiographs over prior to introduction of PACS. With PACS, 56 % spine surgeons flip the radiographs over in clinic and 72 % in theatre so to resemble viewing spine from behind. 56% Surgeons had nearly operated on the wrong side of the spine while 94 % have seen or heard of a patient operated on the wrong side. 72 % Spine surgeons agree that the radiographs should be flipped over so as to resemble the spine as viewed intraoperatively. There is need for a single convention in spine surgery to view radiographs to avoid potential clinical mistakes

Introduction. Sagittal pelvic tilt (SPT) can change with spinal pathologies and fusion. Change in the SPT can result in impingement and hip instability. Our aim was to determine the magnitude of the SPT change for hip instability to test the hypothesis that the magnitude of SPT change for hip instability is less than 10° and it is not similar for different hip motions. Methods. Hip implant motions were simulated in standing, sitting, sit-to-stand, bending forward, squatting and pivoting in Matlab software. When prosthetic head and liner are parallel, femoral head dome (FHD) faces the center of the liner. FHD moves toward the edge of the liner with hip motions. The maximum distance between the FHD and the center in each motion was calculated and analyzed. To make the results more reliable and to consider the possibility of bony impingement, when the FHD approached 90% of the distance between the liner-center and liner-edge, we considered the hip “in danger for dislocation”. The implant orientations and SPT were modified by 1-degree increments and we used linear regression with receiver operating characteristic (ROC) curve and area under the curve (AUC) to determine the magnitude of SPT change that could cause instability. Results. SPT modification as low as 7° could result in dislocation during pivoting (AUC: 87.5; sensitivity: 87.9; specificity 79.8; p=0.0001). This was as low as 10° for squatting (AUC: 91.5; sensitivity: 100; specificity 75.9; p=0.0001) and as low as 13° for sit-to-stand (AUC: 94.6; sensitivity: 98; specificity 83; p=0.0001). SPT modification affects hip stability more in pivoting than sit-to-stand and squatting. Discussion. Our results show the importance of close collaboration between the hip and spine surgeons in treating patients who undergo THA and spinal fusion. The postoperative SPT modification should be considered for preoperative computer simulation for determining the implant safe zone

Introduction. Following the publication of our original survey in 2000 (Eur. Sp. J. 11(6):515-8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpRs), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries. Methods. A postal questionnaire was sent to all 917 SpRs. The questionnaire sought to identify perceptions in spinal surgery, levels of current training and practice, and intentions to pursue a career in spinal surgery. Results. A 61% response rate has confirmed that 74% of trainees intend to avoid spinal surgery (69% in 2000). However 10% are committed to become a Specialist Spinal Surgeon (6.5% in 2000). Their perceptions were wide ranging but most concluded that the intellectual challenge and opportunities for research are widely recognised. However enthusiasm is dampened by poor perceptions of outcomes from surgery, negative somatisation and depression associations, complications and the fear of litigation. In some areas there is inadequate exposure to spinal surgery during the first 4 years of training. Conclusions. Spinal surgery remains a career choice for 10% of surgical trainees (up 3.5% since 2000). With a large SpR expansion (578 to 917 SpRs in the last 5 years) an average of 9 new spinal surgeons annually will be produced over the next six years. This has improved on the figure of 6 per year from 2000. These figures suggest that by 2011 and allowing for retirement, there should be enough spinal surgeons to meet the desired UK/Europe ratio

Introduction: Following the publication of our original survey in 2000 (. Eur. Sp. J. 11. (6):. 515. –8 . 2002. ) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpR’s), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries. Methods: A postal questionnaire was sent to all 950 SpR’s. The questionnaire sought to identify perceptions in spinal surgery, levels of current training and practice, and intentions to pursue a career in spinal surgery. Results: As before, a 70% response rate has confirmed that 74% of trainees intend to avoid spinal surgery (69% in 2000). However 10% are committed to become a Specialist Spinal Surgeon (9% in 2000). Their perceptions were wide ranging but most concluded that the intellectual challenge and opportunities for research are widely recognised. However enthusiasm is dampened by poor perceptions of outcomes from surgery, negative somatization and depression associations, complications and the fear of litigation. In some areas there is inadequate exposure to spinal surgery during the first 4 years of training. Conclusions: Spinal surgery remains a career choice for 10% of surgical trainees (up 1% since 2000). With a large SpR expansion (578 to 950 SpRs in the last 5 years) an average of 16 new spinal surgeons annually will be produced over the next six years. This has improved on the figure of 8.6 per year from 2000 and represents a 200% increase in numbers per year. These figures suggest that by 2011 and allowing for retirement, there should be enough spinal surgeons to meet the desired UK/Europe ratio

Back pain is a complex problem affecting the majority of the population at some point in their life. This cross-sectional study evaluated patients presenting to a tertiary spine clinic with a primary complaint of back pain for modifiable lifestyle factors which may be associated with their back pain. Patients were also asked if any of these lifestyle factors had been addressed by primary care practitioners prior to referral to the spine surgeon’s office. The purpose of this cross-sectional study is to evaluate the modifiable lifestyle factors which may be associated with back pain in patients presenting to a tertiary spine clinic with a primary complaint of back pain and to compare these lifestyle factors with the general population. A secondary objective is to determine whether patients with back pain were given any instructions with regard to modifiable lifestyle factors by their primary care practitioner. Consecutive patients presenting to the orthopaedic spine surgery clinic at the Ottawa Hospital – Civic Campus are asked to complete a questionnaire upon presentation to the surgeon’s clinic and prior to their visit with the surgeon. Data being collected includes Body Mass Index, smoking history, physical activity history, perceived stress, and disability. Information is also being collected on sources of information about back pain including instructions given by primary care practitioners (physician, chiropractor, physiotherapist, massage therapist, acupuncturist, naturopath, and other). Data will be analyzed to determine the difference in modifiable risk factors between patients presenting to the spine surgery clinic and the general population. Data will also be tabulated for numbers of patients being given information on modifiable lifestyle factors by primary care practitioners. To date fifty-two patients have completed the questionnaire. A significant difference has been noted between the number of morbidly obese (BMI > 30) patients presenting to the clinic and the general population. It has been noted that less than 20% of primary care physicians have talked about lifestyle modification with their patients prior to referring them to a spine surgeon. It will be important to know what modifiable lifestyle risk factors this group of patients possesses and which of these modifiable lifestyle risk factors are actually being addressed by primary care practitioners prior to referral to spine surgeons. The current waiting list for an appointment with a spine surgeon at the Ottawa Hospital is six to eighteen months. If surgeons can help primary care practitioners address some modifiable lifestyle factors with their patients prior to their referral, waiting times may be reduced or at the very least made more comfortable for patients

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre. Cite this article: 2015; 97-B:1102–5

Null Hypothesis: All spinal surgeons in the United Kingdom will routinely use X-ray screening in their practice when performing lumbar spinal surgery. Background: Surgery at the wrong level fortunately occurs uncommonly in spinal surgical practice. When it occurs it is a potential source of morbidity for the patient and may result in litigation for the surgeon. The authors analysed the intra-operative x-ray practice of UK spinal surgeons at the time of discectomy, decompression and instrumented fusion. They also assessed their views on surgery at the incorrect level and x-ray facilities available in their centres. Method: 130 members of BASS (British Association of Spinal Surgeons) were sent an anonymous postal questionnaire concerning their practice and views on x-ray use at the time of surgery. Results: 91(70%) questionnaires were returned. There was a large variation in practice between surgeons. 54 percent of surgeons always used x-ray screening for decompression/discectomy procedures whilst 12 percent only used imaging intermittently. The timing of x-ray screening in relation to opening of the ligamentum flavum was also subject to considerable variation. A small number of surgeons never used x-ray screening for pedicle screw insertion and some only used it occasionally. There was a spectrum of opinion on whether wrong level surgery was substandard practice. Conclusion: The Null Hypothesis has been disproved. There is a wide spectrum of practice and opinion on intra-operative x-ray practice among UK spinal surgeons. Some comments, suggestions and recommendations are made by the authors

Background/purpose: Clinical outcomes of surgery for disc herniation and spinal stenosis are variable. Surveys show that post-operative management is inconsistent, and spinal surgeons and their patients are uncertain about what best to do during the recovery phase. The aim of this study was to develop a patient-centred, evidence-based booklet that spinal surgeons can give to their patients to reduce uncertainty, guide post-operative management and facilitate recovery. Methods: A systematic literature search led to a best-evidence synthesis of appropriate information and advice on post-operative activation, restrictions, rehabilitation, and expectations about surgical and functional outcomes. Data were extracted into evidence statements which were graded by consensus for consistency and practicality so as to inform and prioritise the booklet’s messages. Following peer review (n = 16), a sample of patients (n = 11) gave a structured evaluation of the draft text. Results: The review found scant evidence in favour of post-operative activity restriction, yet an early active approach to post-operative rehabilitation can improve clinical, functional and occupational outcomes. Thus, the text of the booklet presents carefully selected messages to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice to aid self-management. Peer reviewers’ comments were incorporated into the text; all the spinal surgeons (n = 7) said they would find the booklet useful. Patients found it readable, interesting and helpful; they understood and accepted the intended messages. Conclusions: Following careful development, an evidence-based booklet to aid post-operative management in spinal surgery is now available, and is factored into a RCT of post-surgical rehabilitation

Purpose of study and background. Clinical researchers use Pfirrmann classification for grading intervertebral disc degeneration radiologically. Basic researchers have access to morphology and instead use the Thompson score. The aim of this study was to assess the inter-observer reliability of both classifications, along with their correlation. Methods and Results. We obtained T2-weighted MR images of 80 human lumbar intervertebral discs with various stages of degeneration to assess the Pfirrmann-score. Then the discs were dissected midsagittally to obtain the Thompson-score. The observers were typical users of both grading systems: a spine surgeon, radiology resident, orthopaedic resident, and a basic scientist, all experts on intervertebral disc degeneration. Cohen's kappa (CK) was used to determine inter-observer reliability, and intra-class correlation (ICC) as a measure for the variation between the outcomes. For the Thompson score, the average CK was 0.366 and ICC score 0.873. The average inter-observer reliability for the Pfirrmann score was 0.214 (CK) and 0.790 (ICC). Comparing the grading systems, the intra-observer agreement was 0.240 (CK) and 0.685 (ICC). Conclusion. With substantial variation between observers, the inter-observer agreements for the Pfirrmann and Thompson grading systems were moderate. This may explain the poor relationship between radiological and clinical observations in patients and raises questions about the validity of the Pfirrmann score. The mediocre intra-observer agreement between the Pfirrmann and Thompson score shows that there is no clear definition of intervertebral disc degeneration. The field is in need for a new, objective and quantitative classification system to better define and evaluate disc degeneration. There are no conflicts of interest. Funded in part by Annafonds Netherlands and Dutch Spine Society

Purpose. A Virtual Spinal Clinic (VSC) was set-up at a regional spinal referral centre to see if patient care could be improved through early advice to provide timely management, early onward referral, improve patient satisfaction and minimise chronicity. The clinic was based on the successful virtual model used throughout the country within orthopaedic fracture clinics. VSC is a Consultant led multi-disciplinary (MDT) clinic run by Advanced Practitioners (AP). Methods. A 3-month trial of the VSC was completed bi-weekly. Patients diagnosed with conservatively managed spinal fractures were referred from the on-call service. A management plan was devised by a Consultant Spinal Surgeon and communicated to patients by the AP via a telephone-call consultation where clinical advice and management could be discussed. Results. 23 clinics completed. 271 patient contacts. 216 reviewed virtually. Completed outcomes of VSC. 34.65% Discharged. 51.18% Routine appointment. 14.17% Urgent appointment. Conclusion. VSC successfully completed safe and timely assessments, management plans, telephone consultations and onward referrals for Greater Manchester patients with acute spinal fractures. Patients had earlier access to health professionals to provide advice, reassurance, complete onward referrals and safety-netting. Patient satisfaction improved, with patient reporting the telephone consultation was reassuring and allowed early return to previous function. VSC reduced patients waiting time for a follow-up appointment and reduced patients travel time across Greater Manchester. In the future, it is hoped that the 6-week follow-up telephone call service will be utilised more as VSC develops. No conflicts of interest. No funding obtained

Aims. Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort. Patients and Methods. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program data files from 2006 to 2013 was conducted to identify patients undergoing common cervical spine procedures. Multivariate logistic regression models were generated to analyse the independent association of functional dependence with 30-day outcomes of interest. Results. Patients with lower functional status had significantly higher rates of medical comorbidities. Even after accounting for these comorbidities, type of procedure and pre-operative diagnosis, analyses demonstrated that functional dependence was independently associated with significantly increased odds of sepsis (odds ratio (OR) 5.04), pulmonary (OR 4.61), renal (OR 3.33) and cardiac complications (OR 4.35) as well as mortality (OR 11.08). Conclusions. Spine surgeons should be aware of the inherent risks of these procedures with the functionally dependent patient population when deciding on whether to perform cervical spine surgery, delivering pre-operative patient counselling, and providing peri-operative management and surveillance. Cite this article: Bone Joint J 2017;99-B:824–8

Purpose: Facet joint arthrosis is an entity that can have a key role in the etiology of low back pain, especially with hyperextension, and is a key component of surgical planning, especially when considering disc arthroplasty. Plain films and MRI are most commonly utilized as the initial imaging of choice for low back pain, but these methods may not truly allow an accurate assessment of facet arthosis. Our purpose was to observe the inter- and intraobserver reliability of utilizing CT and MRI to evaluate facet arthrosis, the inter- and intraobserver reliability of the facet grading system, and the agreement of surgeons as to when to perform disc arthroplasty after the lumbar facets are evaluated. Method: A power analysis was performed which showed we would need 6 reviewers and 43 images to have 80% power to show excellent reliability. 102 CT and the corresponding MRI images of lumbar facets were obtained from patients who were to undergo lumbar spine surgery of any type. 10 spine surgeons and 3 spine fellows reviewed the randomized images at 2 time points, 3 months apart, graded the facet arthosis as well as indicated whether they would chose to perform a disc arthroplasty based on the amount of facet arthrosis. Both interobserver and intraobserver kappa values were calculated by result comparison between observers at the two time points and between CT and MRI images from the same patient. Results: interobserver reliability for MRI was 0.21 and 0.07(fair to slight agreement), and for CT was 0.33 and 0.27(fair agreement), for the spine surgeons and spine fellows respectively. The mean intraobserver reliability for MRI was 0.36 and 0.26 (fair agreement) and for CT was 0.52 and 0.51 (moderate agreement). The kappa value for agreement of whether to perform a disc arthroplasty after grading the facet arthrosis utilizing MRI was 0.22 (fair agreement) and utilizing CT was 0.33 (fair agreement) among the senior spine surgeons. Conclusion: The existing grading system for facet arthrosis and of whether to perform a disc arthroplasty utilizing the grading system has at best only fair agreement. CT is more reliable for grading facet arthrosis

Purpose of the study and background. This audit report outlines a physiotherapy lead spinal triage program for inpatients in a private hospital. The reason to trial this model was proposed as a way to expedite the assessment of inpatients presenting with back pain and implement an appropriate and prompt management plan. Summary of the methods used and the results. An audit tool was developed to record the patient details and outcomes of referrals to the spinal triage program. Length of time between referral and triage was recorded as was the number of patients that went on to require a spinal surgeon consult and spinal intervention. A total of 75 patients were referred into Spinal Triage over a 7 month period. The majority of in patients referred for spinal consult within this private hospital setting were triaged solely by physiotherapy (56%) and a management plan decided on in conjunction with the spinal surgeon on call who could access any imaging remotely. Six patients (8%) involved in the triage program went on to have spinal surgical intervention. Conclusion. Results indicate that the majority of spinal consults at inpatient level do not proceed to require surgical intervention. These results support the model of using Physiotherapists to triage this patient group. I can confirm that this abstract has not previously been published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Source of funding: No funding obtained

Purpose: Few opportunities exist for physicians to easily obtain immediate insights or solicit direct advice from a respected peer on a complicated case. As a result, physicians end up relying heavily on journals, textbooks, and other dated resources that may prove to be dated or inadequate in addressing unique patient problems. Furthermore, the typical training modules available are limited to a one- or two-day experience. Often times this situation does not provide an adequate understanding of the surgical indications, techniques, and potential complications in the application of new technology. Consequently, many surgeons fail to adopt new technologies due to their lack of understanding of the application of such novel technologies. Recently, Reynolds et al studied the effect of peer collaboration among surgeons at a weekly surgery conference. They found that changes in surgical decision-making occurred in 12.5% of all cases reviewed and in 20% of the complex cases. However, collaboration should not be limited to weekly meetings or annual conferences. The Internet has introduced Collaborative Knowledge Networks (CKNs) that allow communities of surgeons to collaborate virtually on complex patient cases—allowing for rapid, bidirectional information. SpineConnect has surfaced as an example of a CKN that allows orthopedic spine surgeons to discuss surgical decisions. Method: We studied the use of Internet collaboration among spine surgeons using the SpineConnect website. We also compared the improvement in the adoption rate of novel technologies using technology fellowships versus traditional training modules. These fellowships use both in-person and virtual collaboration through the Spine-Connect platform as a new means of training physicians. Results: Using the SpineConnect website, surgical decision-making and planning was altered in 34% of active users and 90% agreed that the ability to collaborate with their peers, using a dedicated website, has improved their ability to practice spinal surgery. Continuous communication and dialogue resulting from the technology training fellowships encouraged better understanding of surgical indications, a greater comprehension of surgical technique, and a mechanism to discuss and solve complications. When such fellowships were implemented, we found a 30% improvement in adoption rate over traditional training modules. Conclusion: The treatment of spine surgery patients has benefited from the utilization of collaborative platforms such as SpineConnect. In spine surgeon training and education, we found that CKNs promoted better surgical decision-making and increased understanding of new technology application

The wait times between referral and initial consultation for a spinal surgeon are amongst the highest in the country. Moreover, the vast majority of patients seen by spinal surgeons are not considered appropriate surgical candidates and hence do not benefit from the surgeon’s expertise in surgical management. Identifying inappropriate patients as a method of “triage” may help reduce the wait times. This paper examines two possible “triage” mechanisms – (i.) questionnaire and (ii.) screening by an acute spine pain centre. Phase I identified three simple questions, which were reliable at identifying leg and back dominant pain. These questions were independently administered to a consecutive cohort of fifty-two lumbar patients prior to consultation with one of four spinal surgeons at a tertiary academic centre. Phase II involved an acute spinal pain centre, staffed by pain specialists, who have been orientated on appropriate indications for referral. The mandate of this clinic was to assess patients with acute or subacute back pain within two weeks of referral. A similar questionnaire as the one used in Phase I was independently administered to the first ninety lumbar patients attending the clinic in Phase II. All patients were followed independently to determine if surgery was recommended or performed and compared against the baseline questionnaires, findings on CT/MRI scan or pain specialist’s referrals. The questionnaire identified twenty (38.5%) patients with clearly back dominant pain in Phase I and 56 (62.2%) patients in Phase II. Of the eighteen patients that had surgery or were recommended to have surgery, none had clearly back dominant pain as identified by the questionnaire for a combined sensitivity of 100%. When compared against the patient’s CT/MRI scans in phase I and the pain specialists referrals in Phase II, the questionnaire was more accurate at identifying surgical candidates. This study has demonstrated in multiple settings that a simple questionnaire of three questions can identify patients requiring surgery and may be more specific than standard referrals, CT/MRI scans, or pain specialist’s assessments. Further work is required to refine this screening process and evaluate it prospectively

Background. The rate of subsidence for lumbar fusion surgery is variable from 7- 89%. Subsidance can affect the outcome of surgery by compramising alignment, foraminal height and stability. Modic changes have been shown to affect the stiffness and strength of the vertebral end plate and shown to affect both fusion rates and clinical outcome. Ongoing laboratory investigations into the material properties of the degenerate lumbar spine show modic changes affect the end plate and trabecular bone mechanics. This study aims to bridge this basic science research into clinical practice. Methods. A retrospective analysis of all patients in two tertiary spinal centres who have undergone lumbar interbody fusion with the implantation of a ‘cage’ over the past 6 years were analysed by two independent spinal surgeons. Pre-operative MRI findings were correlated with post-operative interbody cage subsidence after 1 year. Results. A total of 108 Interbody cages were included. Comparison of demographics did not reveal and significant between group variations. Comparison made between those displaying no modic changes and those displaying any of the three modic change types revealed a significantly higher subsidence rate in those displaying modic changes (p=0.003). Subgroup analysis showed that Type 2 modic changes (n=27) had a significantly higher subsidence rate (p=0.002). Those displaying type 3 modic changes (n=7) did not have any incidents of subsidence. Conclusions. Type 2 modic changes are associated with a higher rate of Lumbar interbody cage subsidence in this study. Those displaying type 3 changes seem to be protected from interbody cage subsidence. No Conflict of Interest. Funding: Produced as part of a research grant from the Gwen Fish Trust and Action Arthritis

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

Purpose:. To examine the feasibility of surgical outcome measures for a children's orthopaedic surgeon when compared with other specialties. Methods & Results:. Details of procedure codes for 2726 inpatient episodes were used to examine the distribution of procedures and the breadth of diagnoses dealt with by a variety of orthopaedic sub-specialists. The author's practice included 199 surgical cases and was compared with two arthroplasty surgeons (n=971); a spinal surgeon (n=256); a foot and ankle surgeon (n=341) and an upper limb surgeon (n=393). Arthroplasty surgeons can report 50% of their outcomes as primary knee or hip replacements the index procedure for the author is metalwork removal (14.5%). My upper limb colleague could be judged on 25% of his cases (carpal tunnel decompression) and my spinal surgical colleague on 20% of his cases (primary posterior decompression of spinal cord). Only my foot and ankle colleague compared in terms of diversity with 9% of his cases consisting of first metatarsal osteotomy and the next 9% consisting of 1st MTPJ arthrodesis. The proportion of multiple procedures also varies between sub-specialists with 66% of my cases being multiple compared with 38% for the arthroplasty surgeons and 42% for the upper limb surgeons. Foot and ankle has a high rate of multiple procedures (62%) and the spinal surgeons code different procedures at each level in the spine giving the high rates of multiple procedures. Conclusion:. Outcome measures in children's orthopaedics seem problematic owing to the diverse nature of the practice and the confusion resulting from multiple procedures contributing to the outcome in 60% of cases. Either we are treated like physicians who do not have surgical outcomes to report or some goal based measure is adopted. Level of evidence: III

The December 2013 Spine Roundup. 360 . looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space

Aims

To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

To determine if the term “back pain” has uniform meaning to spinal surgeons. A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain. An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting. 67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05). The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral. This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Purpose: Magnetic resonance imaging (MRI) is the diagnostic imaging modality of choice for spinal disorders. The high prevalence of “abnormal” MRI findings within asymptomatic individuals is well established, however, referrals to spine surgeons are often based on symptomatically discordant or non-surgical MRI ‘abnormalities’. The purpose of this study was to determine the prevalence of typical spine MRI abnormalities among symptomatic surgical candidates (SC) and non-surgical (NS)patients. Method: A retrospective cohort study was conducted on 1,585 patients (with a lumbar MRI) seen by a spine surgeon. The cohorts were compared in terms of the total amount, type, severity and number of levels of abnormalities on MRI. All patients were prospectively stratified regarding surgical candidacy. Results: There was no difference between the cohorts (n=722-SC / 863-NS) in terms of the total amount of structural abnormalities present (p=0.26). There was no difference in the prevalence of DDD, disc-herniation or previous surgery (p> 0.2). However, there was a higher prevalence of spinal stenosis (0.513 vs. 0.394) and spondylolisthesis (0.263 vs. 0.112) within the SC (p≤0.01). Logistic-regression showed that patients with disc-herniation, stenosis or spondylolisthesis were 1.49, 1.61 and 2.84 times more likely to be SC respectively (p≤0.001). Subjects with a report of severe/large herniation or stenosis were 3.30 and 2.25 times (p< 0.001) more likely to be SC respectively. Patients with one-level anomalies were 2.19 times (p< 0.0001) more likely to be SC. Conclusion: It is hopeful that these results will better enable non-surgeons to more effectively identify and educate patients with a higher likelihood of being surgical candidates

Aim. To evaluate the level of health resource utilisation by patients after lumbar total disc replacement (TDR) for mechanical low back pain. Method. At our centre, 35 patients underwent TDR and were followed prospectively from surgery. All surgery was performed by the senior author. Patients were followed routinely in clinic at yearly intervals. In addition, the patients and their GPs were contacted via telephone. Information gathered included ODI and VAS, satisfaction with surgery and return to work. We specifically established whether the patients continued to seek healthcare, for persistent back symptoms, from professionals (both NHS and private) including their GP, pain clinic, physiotherapist, acupuncturist, chiropractor or another spinal surgeon, and had any further interventions. Results. We have complete dataset on 30 out of 35 patients and are the subject of this study. There were 13 men, with a mean age of 37.7 years (range 28-45 years), and 17 women with a mean age of 49.8 years (range 27-62 years). Surgery was single level in 26 and two levels in 6 cases. Patients were satisfied with the outcome of surgery in 21 cases (70%), not satisfied in 7. Two cases had implant failures. 25 patients were working pre-operatively and 26 were working postoperatively. Eighteen patients required no further healthcare input. Five had had pain clinic reviews, six had seen their GPs (1-6 visits) and one another spinal surgeon (after late liner extrusion). Seven had facet injections and two had epidurals. One patient underwent posterior fusion for implant migration. Conclusion. In our series TDR is successful in 70% and 60% of the entire cohort needed no further healthcare input. After successful TDR there is almost no ongoing use of health resources

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

We present an analysis of manual and computer-assisted preoperative pedicle screw placement planning. Preoperative planning of 256 pedicle screws was performed manually twice by two experienced spine surgeons (M1 and M2) and automatically once by a computer-assisted method (C) on three-dimensional computed tomography images of 17 patients with thoracic spinal deformities. Statistical analysis was performed to obtain the intraobserver and interobserver variability for the pedicle screw size (i.e. diameter and length) and insertion trajectory (i.e. pedicle crossing point, sagittal and axial inclination, and normalized screw fastening strength). In our previous study, we showed that the differences among both manual plannings (M1 and M2) and computer-assisted planning (C) are comparable to the differences between manual plannings, except for the pedicle screw inclination in the sagittal plane. In this study, however, we obtained also the intraobserver variability for both manual plannings (M1 and M2), which revealed that larger differences occurred again for the sagittal screw inclination, especially in the case of manual planning M2 with average differences of up to 18.3°. On the other hand, the interobserver variability analysis revealed that the intraobserver variability for each pedicle screw parameter was, in terms of magnitude, comparable to the interobserver variability among both manual and computer-assisted plannings. The results indicate that computer-assisted pedicle screw placement planning is not only more reproducible and faster than, but also as reliable as manual planning

Background Changes in professional boundaries have allowed many of the tasks traditionally undertaken by doctors to be delegated to Nurses and Allied Health professionals. The employment of an appropriately experienced specialist physiotherapist in orthopaedic clinics in the NHS to triage patients is well established. This paper examines the background, establishment and outcomes of the use of a Physiotherapist Extended Scope Practitioner (ESP) in the Orthopaedic Department at the Royal Hospital Haslar, Gosport. Method The post at RH Haslar has evolved in the five years since its implementation. All military patients referred to RH Haslar Orthopaedic Department with spinal, predominantly low back, pain are assessed in the Military Spinal Triage Clinic. The Physiotherapist ESP case-manages patients with access to radiological and haematological investigations and onward referral to other specialities as appropriate. Results In eighteen months 235 new patients have been assessed. Only 25 patients required review by the consultant spinal surgeon, while 5 were referred to non-spinal orthopaedic consultants with shoulder/hip pathology. A total of 18 patients were referred to Pain Clinic and 3 patients to rheumatology. The results indicate that nearly 90% (n=210) of patients who would previously been reviewed by a consultant spinal surgeon could be managed by a Physiotherapist ESP. The waiting time to spinal surgery has reduced from approximately 8 months to between 6 and 16 weeks. Conclusions It is concluded that an appropriately trained specialist physiotherapist is clinically and economically appropriate to manage patients in an Orthopaedic Department. This has important implications for optimising patient management and additionally supports the wider clinical employment of senior military physiotherapists

Cite this article: Bone Joint Res 2023;12(5):306–308.

Three developments in the last 10 to 15 years have made it necessary to review how we ensure rapid access to treatment of patients with disabling low back pain. Firstly, there would appear to be an increase in the numbers of patients seeking medical help for low back pain, whether due to increased patient expectation, or better reporting, or a true increase associated with the increasing sedentary nature of life, is uncertain. Secondly, there is the realisation that amongst the factors that encourage acute back pain to become chronic is being off work, and the sooner a diagnosis and treatment is started the more likely that chronicity will be prevented, so a long waiting time to be seen in a clinic is productive of disability. Thirdly, reorganisation of consultant services has created the spinal surgeon, who in return for being allowed to practice spinal surgery almost exclusively undertakes the load of patients referred with back pain, amongst whom lurk those with a surgically remediable problem. The effect has been that although waiting times for general orthopaedic patients have dropped, as general orthopaedic, or other specialist orthopaedic surgeons no longer see spinal cases, the specialist spinal surgeon is overwhelmed by a large group of patients with back pain for whom there is not a surgical solution. Unfortunately, there is a shortage of spinal surgeons, which is likely in the UK at any rate to get worse. Being overwhelmed with non-surgical back pain interferes with their ability to deal with surgical problems. It also does create a recruitment problem, as back pain is not seen as a rewarding or satisfying problem to treat. Triage is a method of screening patients into groups at an early stage, identifying those who might benefit from surgery, and fast tracking them, identifying those who will benefit from other management and tracking them accordingly. Pioneered in general orthopaedics by Robin Ling in Exeter, it has been developed in the hospital setting somewhat randomly, by dedicated enthusiasts, many of whom will be speaking today. The purpose of this meeting today is to hear about the various systems, their funding and organisation and location, the triage staff used, the investigations used in primary triage and the effect on hospital specialist waiting times, the safety and patient satisfaction. Is a multiplicity of systems best, is one better than another, why have some units achieved no waiting times for MRI, and others six months etc?. In 1994, the Clinical Standards Advisory Group produced two books, An epidemiological Review, largely the work of Gordon Waddell, and a second book on Back Pain, chaired by Professor Michael Rosen with, I suspect, considerable input from Professor Waddell and others. Many of us met them when they toured the country collecting facts about the treatment and management of back pain. It discusses back pain triage, and suggests that it can be done within the average GP Consultation time of 9 minutes. It deals with simple back ache, “red flags”, (we now have “yellow flags” denoting the psycho-social factors) nerve root pain, cauda equina and inflammatory disorders. It is to be noted that chronic back pain, is not alluded to in the diagnostic triage, but it is stated that 90% of simple back ache recovers in six weeks. Their management guidelines emphasise the value of physical therapy (manipulation and active exercises), but it will be noted that they are addressed to a group of patients, 90% of whom will recover in six weeks. Sadly, therefore, the effect of this very sensible document, in ignoring in the triage system the chronic patient, has in many cases directed therapy in general practice towards open access for patients who in any event will improve spontaneously. We must therefore address where triage should be, hospital, or GP level. Certainly a GP gatekeeper will remove the acute back pains that are going to get better soon anyway from attending hospital and in certain units, a separate fast track is provided for acute radicular problems (Acute Sciatic Clinics). Any successful triage system involving chronic back pain must be associated with treatment possibilities, and I shall briefly discuss these, although the main thrust of the afternoon will be the triage organisation itself. The session is designed to allow considerable audience participation, as it is hoped that information, comments and criticisms from the audience will allow us to subsequently produce a booklet, hopefully with support from our Professional Societies, describing what we feel is Best Practice in Back Pain Triage, which we hope, after appropriate circulation, will encourage Trusts and Community Health Groups to develop such units and ensure that back pain patients get a better deal

Background. Previous research in people with musculoskeletal low back pain (MLBP) in primary care shows that a reliable and valid measure of consultation-based reassurance enables testing reassurance against patient' outcomes. Little is known about the role of reassurance in people with MLBP consulting spinal surgeons, especially in cases where surgeons recommend not to have surgery. There might be several reasons to exclude surgery as a treatment option, that range from positive messages about symptoms resolving to negative messages, suggesting that all reasonable avenue of treatment have been exhausted. AIM to explore patient's experience of consultation-based reassurance in people with MLBP who have been recently advised not to have surgery. Methods. Semi-structured interviews were conducted with 30 low back pain patients who had recently consulted for spinal surgery and were advised that surgery is not indicated. Interview were audio recorded and transcribed, and then coded using NVIVO qualitative software and analysed using the Framework Analysis. Results. Most patients reported feeling dismissed and discouraged. They considered that consultants were better in relationship building and data gathering than in providing cognitive and generic reassurance. Major emerging themes included the complexity and confusion of their NHS journey, lack of continuity-of-care, lack of information for their condition and a sense of dismissal. Patients reported that they needed reassurance through clear explanations and discussion of pain management, but instead were discharged into a void. Conclusion. Effective communication with patients attending surgical settings to consult about their back pain is important, especially when no active treatment is being offered. No conflict of interest. Funded by a grant from EuroSpine awarded to Professor Tamar Pincus and carried out within the NHS

The February 2024 Spine Roundup³⁶⁰ looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?

The August 2024 Spine Roundup³⁶⁰ looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture.

The February 2023 Spine Roundup³⁶⁰ looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study.

Background. Almost 80% of people experience low back pain at least once in their life. A quarter suffers from Nonspecific Chronic Low Back Pain (NS-CLBP), where symptoms cannot be justified radiologically. There is evidence that imaging negatively impacts outcomes (increased painkillers and doctors' visits) in NS-CLBP patients. Despite clinical guidelines recommending against the use of imaging, healthcare practitioners and patients still request imaging to explain symptoms. Method. Qualitative, semi-structured interviews with NS-CLBP patients, physiotherapists, and doctors conducted using purposeful sampling of 6–11 people from each group. The interviews were recorded, transcribed and analysed using framework analysis. Validity was ensured by data triangulation with participants. Results. Interviews with 11 patients who had an MRI scan, 6 physiotherapists and 6 spine surgeons. Four main themes emerged from synthesis of findings across these three groups. Discussion. This study provides an insight of the lived experience of NS-CLBP among three different groups. It highlights the difference in expectation between healthcare provider and patients about how CLBP should be managed and the lack of coordination between primary and secondary healthcare services. Although patients seek imaging to explain NS-CLBP, they react to the results negatively. In accordance with fear avoidance model, participants reported fear avoidance behaviours and anxiety following MRI. That affect daily life activities and participation. Conclusion. This study highlights the need for early management of NS-CLBP patients in primary care. The psychosocial consequences of diagnosing by MRI are fear avoidance and anxiety. The current biomedical education to those patients may promotes these consequences. Conflict of interest. No conflicts of interest. Study fund. This research was supported through a PhD scholarship from Prince Sattam bin Abdul-Aziz University, Saudi Arabia, at the University of Nottingham, United Kingdom

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We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

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This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer.

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The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

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Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

Treatment regimes for malignant disease have improved significantly in recent years leading to improved survival after diagnosis of primary and Metastatic disease. Against this background we have reviewed the activity in a district general hospital offering a spinal service to evaluate the efficacy of surgery in metastatic disease. Materials and Methods: Retrospective casenote review of patients identified through theatre records over a 3 year period. 27 patients were identified as having surgery for spinal tumours, of whom 24 were for metastatic disease. All presented with pain and/or signs of acute cord compression and had an intervention on an urgent or emergency basis by one of three spinal surgeons. Results: Of the 24 patients with metastases, the primary tumours were breast (7), lung(7), prostate(2), renal(2), bladder(1), clear cell (1), colon(1), thyroid(1) and unknown (2). The operations performed were: spinal decompression or vertebrectomy and stabilisation(18), stabilisation without decompression(4), decompression alone (1), biopsy only (1). Mean survival after surgery was 9.4 months (range 0–42 months) with a poorer outcome in those with pulmonary and renal disease. 7 patients remain alive with a mean follow up of 21 months. Symptomatic improvement was recorded in 19 / 24 patients in terms of pain control and/or restoration of function. There were 4 perioperative deaths of which none were due to complications of surgery. Discussion: Patients with terminal diseases are challenging to treat as they require multidisciplinary input both in hospital and in the community. Good results can be achieved for both symptom control and pain relief by surgical intervention for spinal metastases if appropriate early referral is made to a spinal surgeon. We have found that with the general improvements in survival with malignancy an aggressive surgical regime of decompression or vertebrectomy with spinal stabilisation can be supported

A prospective cohort outcome evaluation of unstable thoracic spine fractures treated with posterior pedicle screw fixation. The purpose of this study was to determine the accuracy of placement and safety of pedicle screws in open reduction of unstable thoracic spine fractures. The surgeries were performed by one of five fellowship trained spinal surgeons. CT scans were formed on twenty-three patients totaling two hundred screws using 3mm cuts. Three independent reviewers assessed and categorized the screw position as within the pedicle or as a violation of the pedicle wall. 98% of the screws were accurate and we recommend the use of pedicle screws in thoracic fractures . A prospective cohort outcome evaluation of unstable thoracic spine fractures treated with posterior pedicle screw fixation. This study is to determine the accuracy of placement, safety of pedicle screws in open reduction of unstable thoracic spine fracture. Surgery was performed by one of five fellowship trained spine surgeons. CT scans were performed on twenty-three patients using 3mm cuts in both sagittal and transverse planes. Pedicle screw position was assessed by three independent reviewers. Screw position was categorized as within the wall of the pedicle or in violation of the wall. Further sub-classification of pedicle wall violation reviewed the direction and distance of perforation. Independent perioperative and postoperative surveillance for complications was done. Twenty-three unstable thoracic spine fractures treated with two hundred posterior pedicle screws were analyzed. The pedicle screws spanned from T1-T12 with the majority of screws in the mid-thoracic region. Of the two hundred thoracic pedicle screws placed, 70% were fully contained within the pedicle wall. The remaining screws were deemed “out” with cortical perforation (30%). Of these, 20% were lateral perforations, 5% were medial perforations and 5% were anterolateral perforations. No superior, inferior, or anteromedial perforations were found. There was no regional area variation in incidence of perforations. 10% of all perforations were directly related to pedicle diameter to screw diameter mismatch. There were no adverse neurological, vascular, or visceral injuries detected intraoperatively or postoperatively. Surgical management of unstable thoracic spine fractures with posterior pedicle screw fixation is safe. 98% of screws had satisfactory accuracy. Although very minor misplacement of pedicle screws occurred, there were no complications and we recommend the use of pedicle screws in thoracic fractures

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Introduction Symptomatic Thoracic disc prolapse (TDH) is a rare condition, with approximately 1 case per million population presenting per year. There are not many Spinal surgeons with a significant experience in the management of these lesions which necessitate a familiarity with the anatomy of the thorax and thoracic spinal cord. TDH is often diagnosed on modern imaging, but the indications for surgery in asymptomatic cases or in patients with spinal pain only, remain undefined. The natural history of TDH is not known and there is a poor correlation between the radiological and clinical presentation. The advent of newer minimally invasive endoscopic techniques for TDH may have reduced the incidence of open procedures for this condition, but may lead to an increase in operations performed for TDH, especially in cases where the surgical indications remain uncertain. In a small country like New Zealand it is especially difficult to build up a large series and to become very familiar with what remains a difficult operation. Methods The Neurosurgical experience with this condition in Auckland over the last ten years was reviewed. Clinical presentation, diagnostic imaging, surgical management and patient outcome were analyzed. Results Twenty-one patients were treated over the last 10 years. All had symptomatic TDH. Most operations were performed by the senior author. Patient age varied between 30 and 80, with mean age 50.8 years. There was a slight female preponderance (n=14). Most patients were of European ethnicity. Most patients had spinal cord or nerve root dysfunction, but local pain and sensation change were also noted. MRI was the mainstay in diagnosis, and CT scan was often also used. Surgical exposure was aimed at avoiding spinal cord manipulation and will be discussed. The surgical approach was via thoracotomy in most cases, costotransversectomy, pediculectomy and laminectomy. One case was treated conservatively. There was one case of postoperative paraplegia which will be discussed. There were no other permanent major neurological complications. Patient outcomes will be discussed in detail. Patients with motor weakness showed post operative improvement or full recovery. Pain and sensory loss symptoms were less likely to resolve. Complications that warrant discussion included temporary cranial nerve palsy, thoracic empyema, and long-term opioid addiction for pain. Discussion Over the past 10 years, a reasonable number of patients with TDH have been treated surgically without major incident. The surgical management of this condition remains a challenge. Younger spinal surgeons may not have the training to deal with these cases, which should be addressed. Endoscopic treatment has a steep learning curve, and may not be well suited to larger symptomatic TDH

Introduction. Guidelines from the North American Spine Society (2009 and 2013) are the best evidence-based instructions on venous thromboembolism (VTE) and antibiotic prophylaxis in spinal surgery. NICE guidelines exist for VTE prophylaxis but do not specifically address spinal surgery. In addition, the ruling of the UK Supreme Court in 2015 resulted in new guidance on consent being published by the Royal College of Surgeons of England (RCSEng). This study assesses our compliance in antibiotic, VTE prophylaxis and consent in spinal surgery against both US and UK standards. Methods. Retrospective review of spinal operations performed between August and December 2016. Case notes, consent forms and operation notes were analysed for consent, peri-operative antibiotic prescribing and post-operative VTE instructions. Results. Four Spinal surgeons performed 45 operations during this period. 31 patients (69%) received a copy of the signed consent with this process being formally documented in 22 (71%) of those cases. All patients were consented by a competent surgeon. 82% of cases consented prior to the date of procedure were countersigned on the day of operation. There was a mean time of 25.3 days between initial consent and operation (Range: 0–170). 37 (82%) cases had clear instructions for VTE and antibiotic prophylaxis. All prescribed post-operative antibiotics were administered. Discussion. The North American Guidelines state that prophylactic antibiotic is appropriate in all spinal surgery with prolonged cases requiring intraoperative re-dosing and only complex cases needing a postoperative regimen. Eight patients underwent a complex procedure and 7 appropriately received postoperative antibiotics. Of the 29 patients that underwent a simple procedure, 12 did not receive post-operative regimen, in line with the guidelines. However, the remainder 17 were over treated. The US Guidelines recommend mechanical VTE prophylaxis only in elective spinal surgery except in high risk patients. All our patients received VTE mechanical prophylaxis. RCSEng guidelines require consent being taken prior to procedure by a competent surgeon and confirmed on day of procedure. All patients in our cohort were consented prior to the date of operation allowing time for considering options and independent research. 82% of patients had consent confirmed on day of operation. Conclusion. This study demonstrates that we met guideline advice for all patients with regards VTE prophylaxis. We have a tendency to over treat with post-operative antibiotics and not all patients had their consent confirmed on day of procedure but was consented well before day of operation. North America still lead the way with guidelines on spinal surgery to which we should adhere, with NICE guidelines providing limited instructions. New consenting guidelines from RCSEng may not be currently widely known and thus should be a source of education for all surgeons

Dislocation and accelerated wear have been the nemesis of hip surgeons. No study has been able to correlate cup position to instability. In recent years the influence of the spine-pelvis-hip construct has emerged as important to understand the shift in component position with postural change. Using measurements familiar to spine surgeons, we have correlated the pelvic incidence (PI), a static measurement of pelvic width and hip position; the static tilt, a dynamic measure of pelvic-spine mobility. For THR we have measured the sagittal cup position as the fixed angular change of the cup shifts with pelvic tilt, and this is named anteinclination; and the sacral acetabular angle (SAA) which is the relationship of the acetabulum to the absolute value of sacral tilt (ST) in both standing and sitting. The pelvic femoral angle (PFA) is a measure of femur/hip flexion/internal rotation correlated to pelvic mobility. Dislocation is most common in patients with low PI combined with an ST change <15 degrees. With normal PI and high PI, it occurs much less commonly and only in patients with ST change <5 degrees (very stiff). In patients with stiff pelvis (ST<13) the cup needs increased inclination and anteversion (45/20–25) to compensate for absence of cup opening by posterior tilt of pelvis. For patients with low PI and stiff pelvis we recommend constraint (such as dual mobility articulation)

Background: Surgical treatment of spinal deformities is complex and is performed by a limited number of spine surgeons. To obtain adequate radiological and clinical correction, a large amount of clinical experience is required when planning corrective surgery because of the enormous amount of patient related variables, and the many surgical techniques (e.g. rod rotation vs translation, pedicle screws vs hooks, anterior vs posterior). The widely used classification systems (King and Lenke) are useful for documentation of the deformities. Unfortunately explicit guidelines for surgery are not clear. A multi-centre database with pre and postoperative patient data including photographic images and x-rays will be very useful in decision making. It will allow surgeons to find similar cases in the database that will help them in their decision making for surgical planning and execution. Furthermore it will provide extensive data to perform outcome studies, and to develop general treatment guidelines. Surgery for spinal deformities will become more evidence based and less dependent on the individual surgeons judgement. Methods: A modern web-based database system, Scolisoft was developed for documenting patient data and curve characteristics. The system contains patient data (demographics etc), radiological data (AP, Lat, bending films), classification of curve patterns according to the often-used classification systems and information about the surgical procedure. It includes pre and postoperative radiological data and clinical photographs. The patient data can also be stored and printed as a PDF-file, so that it can be used as a patient chart and for patient information purposes. Scolisoft allows the user to select patients based on all the individual characteristics, e.g. curve classification. For pre-operative planning of a specific deformity, a cohort of patients with the same deformity (patient demographics, curve pattern, bending films etc) can be selected and the postoperative results viewed. With the same selection tool, cohorts of patients can be selected for outcome studies. Furthermore Scolisoft provides the possibility of discussing difficult cases with other spine surgeons using the system. Finally, complications are registered according to the existing Scoliosis Research Society complication registry system. Experiences: Data of more than 200 patients have been entered into the former PC application system. The current web based system has 60 cases that have been entered during its trial phase. Most cases have been adolescent or adult idiopathic scoliosis. Forty two surgeons have used the software and eight surgeons have participated in entering cases. The web-based version has shown to be very user friendly. Submitting the radiological and clinical images is easy (but takes some time). All data input is possible by a simple click of the mouse. Therefore it is relatively easy to learn. The system already has the possibility for documenting other spine pathology such as sagittal plane deformities, fractures and spondylolisthesis. Conclusion: Scolisoft is a powerful, user-friendly web-based registry for spinal deformities. It is a very useful tool in planning spinal deformity surgery and research. In this time of evidence-based medicine, it is time to take the planning of scoliosis surgery out of the realm of myth, and this database is a strong step in that direction

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months. Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (. sd. 5.26) vs 10.1 months (. sd. 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients

Aims

Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse.

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The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°). These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately

Background. Percutaneous endoscopic interlaminar discectomy (PEID) has achieved favorable effects in the treatment of lumbar disc herniation (LDH), as a new surgical procedure. With its wide range of applications, a series of complications related to the operation has gradually emerged. Objective. To describe the type, incidence and characteristics of the complications following PEID and to explore preventative and treatment measures. Study Design. Retrospective, observational study. Setting. A spine center affiliated with a large general hospital. Method. In total, 479 cases of patients with LDH received PEID, which was performed by an experienced spine surgeon between January 2010 and April 2013. Data concerning the complications were recorded. Result. All of the 479 cases successfully received the procedure. A total of 482 procedures were completed. The mean follow-up time was 44.3 months, ranging from 24 to 60 months. The average patient age was 47.8 years, ranging from 16 to 76 years. There were 29 (6.0%) related complications that emerged, including 3 cases (0.6%) of fragment omission, and the symptoms gradually eased following 3–6 weeks of conservative treatment; 2 cases (0.4%) of nerve root injury, and the patients recovered well following 1–3 months of taking neurotrophic drugs and functional exercise; 15 cases (3.1%) of paresthesia, and this condition gradually improved following 3–6 weeks of rehabilitation exercises and treatment with mecobalamin and pregabalin; and recurrence occurred in 9 cases (1.9%), and the condition was controlled in 4 of these cases by using a conservative method, while 5 of the cases underwent reoperation, including 3 traditional open surgeries and 2 PEID. Furthermore, the complication rate for the first 100 cases was 16%. This rate decreased to 3.4% (for cases 101–479), and the incidence of L4–5 (8.2%) was significantly higher than L5-S1 (4.5%). Limitations. This is a retrospective study, and some bias exists due to the single-center study design. Conclusion. PEID is a surgical approach, which has a low complication rate. Fragment omission, nerve root injury, paresthesia and recurrence are relatively common. Some effective measures can prevent and reduce the incidence of the complications, such as strict indications for surgery, a thorough action plan and skilled operation skills