Summary

The required torque leading to an abrasion of the passive layer in the stem-head interface positively correlates to the assembly force. In order to limit the risk of fretting and corrosion a strong hammer blow seems to be necessary.

Study Design

Single surgeon prospective cohort with radiological follow-up.

The purpose of this cohort study is to determine the incidence of all congenital vertebral anomalies detected antenatally through ultrasound. We also reported on the early mortality rate for this patient cohort, as well as the frequency and type of associated congenital anomalies.

The East Midlands and South Yorkshire Anomalies Register consists of data on all voluntary reports of congenital anomalies, from an annual baseline birth rate of 67000 births. We analysed all registered congenital anomalies reported over a 10 year period.

Between January 1997 and January 2007, 108 vertebral anomalies were reported, excluding spinal dysraphism (incidence 0.01%). 61 of these were detected antenatally (56%), 17 were detected postnatally (16%) and in 30 patients, the precise time of diagnosis was unclear (28%).

At the time of analysis January 2007, 45 of 108 patients had died, either in utero or soon after delivery (42%). 12 fetuses remained in utero and 51 infants were alive. The mortality rate for antenatally diagnosed patients was 41% and the majority were electively terminated (72%). 2 fetuses electively terminated had vertebral anomalies in isolation.

There is a relatively high incidence of elective termination of pregnancy as a result of antenatal anomaly ultrasound screening. We have evidence to suggest that foetuses with potentially minor congenital anomalies are being electively terminated at approximately 18 weeks gestation. A structured and timely spinal counselling should be offered once antenatal vertebral anomalies have been identified.

The purpose of this study was to ascertain whether early diagnosis through antenatal ultrasound screening and intervention lead to a reduction in morbidity associated with congenital scoliosis.

Prospective cohort study

All fetuses with vertebral body anomalies detected over a thirteen years period were included. Maternal risk factors, accuracy of antenatal diagnosis, associated fetal anomalies and ultimate outcome are described.

Twenty-four fetuses with congenital hemivertebrae were identified from 39,000 antenatal scans (incidence 0.061%). The mothers' median age at conception was 26 years (range 18-40 years). The median fetal gestational age at diagnosis was 20 weeks (range 18-38 weeks). The median gestational age at delivery was 38 weeks (range 27-40).

Antenatal ultrasound identified eighteen fetuses with a single hemivertebra, six fetuses with multiple hemivertebrae. Eleven patients (50%) have undergone early surgical intervention with median post-natal follow up was 4 years (range 0-9 years). The median age at surgery was 12 months (range 1.2 - 47 months). The median pre-operative Cobb angle was 33 degrees and the median Cobb angle at final follow up was 25 degrees.

In this series 50% of patients required surgical intervention. We felt that pre-natal diagnosis of congenital vertebra abnormally has resulted in early surgical intervention using less complex surgical technique to halt progressive deformity. However, further studies are required to compare the results with the abnormally not detected antenatally.

Objectives

The main objective of our study was to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined whether there was any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Objectives: To determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. Secondary investigations were on the requirement for subsequent interventions such as root blocks and/or surgery. A sub group analysis between sciatica and stenosis was undertaken.

Study Design: A randomised, double blind controlled trial.

Subjects: 150 eligible patients with radicular pain and unilateral chronic symptoms were randomised for a single injection with bupivacaine and methylprednisolone (b+s) or bupivacaine (b) alone.

Outcome measures: The outcome measures included the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg pain and back pain and patient’s subjective level of satisfaction of the outcome.

Results: 76 patients in the b only group and 74 patients in the b+s group.

Clinically useful improvements of greater than 10 points on the ODI occurred in 54%, deterioration of 10 points or more occurred in 17%. Visual analogue for leg improved by 2 or more in 63%.

There was no statistically significant difference between the groups at 3 months (change in ODI [p=0.2], change in VAS [back pain, p=0.28; leg pain, p=0.67]. Subgroup analysis revealed no statistically significant difference in the change in scores between the stenotic group and disc herniation group at 3 months. At 1 year follow-up data was available for 86% of the patients. There was no statistically significant difference in the rate of further interventions.

Conclusion: Clinical improvement occurs in both groups of patients. Corticosteroids did not provide additional benefit. There is no difference in the need for further root blocks or surgery.

Purpose: To assess the effectiveness of nasal salmon cal-citonin in the treatment of lumbar spinal stenosis

Methods: Forty patients with symptoms of neurogenic claudication and MRI proven lumbar spinal stenosis were enrolled into the study. They were randomly assigned to either nasal salmon calcitonin 200 i.u or placebo nasal spray (sodium chloride) for the first 4 weeks. At the end of the 4 weeks of initial treatment the patients were given a 6 weeks washout period, during which they received no further nasal spray and were instructed to continue with their normal analgesics. At the end of this period all patients received a further 6 weeks of active nasal salmon calcitonin.

Outcome measures: Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg and back pain, Shuttle Walking Test Distance in metres.

Results: In the 4 weeks during which patients received active/placebo nasal salmon calcitonin there was no statistically significant difference in the change in outcome scores between the two groups (change in ODI [p=0.51], change in VAS for leg pain [p=0.51] and change in shuttle walking distance [p=0.78]) There is a minimal improvement in the mean ODI at the end of only 3.7 points in the calcitonin group and 3.8 points in the placebo group [p=0.44]. The VAS for leg pain deteriorated in both groups. There was a minimal improvement in the VAS for back pain in the calcitonin group of 5 mm, it deteriorated in the placebo group by 11mm [p=0.03]. At the end of the trial 9 patients (23%) reported either an excellent or good outcome, 6 reported a fair outcome (15%) and 17 patients (43%) reported a poor outcome.

Conclusion: This dose of Nasal salmon calcitonin is not effective in the treatment of patients with lumbar spinal stenosis.

To evaluate prognostic factors that influence outcome particularly those related to duration of symptoms in surgery for lumbar radiculopathy, #2

In primary care 75% of patients are pain free after the onset of sciatica within 28 days. The optimum timing of surgery for unresolved leg pain secondary to herniated lumbar disc is unclear.

#2 We prospectively recruited 113 patients in this study and at one year, the follow up was available on 103 (91%). We investigated the prognostic value of a number of variables. These included the duration of sciatic symptoms, age at operation, Modified Zung Depression Score (MZD) and Modified Somatic Perception Score (MSP) using multiple regression analysis. The outcome was measured by the change of the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS) and of the Visual Analogue Scale (VAS). Patients with contained and non-contained herniated disc were compared.

The change in ODI is statistically significantly associated with the duration of sciatica symptoms (p=0.05) with a one-month increase in the duration of symptoms being associated with a decrease in the change of ODI of 0.6% (95% CI, −1.014 to −0.187). The duration of sciatica and the MZD are associated with significant reduction in LBOS (p=0.034 and 0.028 respectively). VAS was not significantly associated with all the prognostic factors investigated.

A shorter duration of sciatic symptoms was associated with a greater degree of patients’ outcome satisfaction. Non-contained herniated disc had a shorter duration of symptoms and a better functional outcome compared to contained herniated disc. Unemployment and smoking were not risk factors for poor surgical outcome.

Conclusion: Our study indicates that the duration of radicular pain of more than 12 months has a less favourable outcome. Patient’s satisfaction is greatest if surgery occurs within one year.

This study investigates the efficacy of the AO Pi-plate in the treatment of complex, unstable, intra-articular fractures of the distal radius.

A retrospective study of 17 patients was carried out who underwent open reduction and internal fixation for dorsally displaced, intra-articular fractures of the distal radius using the AO Pi-plate. All patients were assessed clinically and radiologically post-operatively. The final functional outcome was assessed using the Gartland & Werley scoring system.

The average follow-up period was 34.3 months. 94% (16 patients) of the fractures were classified as AO type C fractures. The wrist movement was restored to a near normal range in all cases. The mean grip strength was 67% of the uninjured hand. The functional outcome as measured by the Gartland & Werley scoring system showed excellent and good results in 88% of the patients. Radiographic assessment revealed an average articular step-off of 0mm post-operatively. The implant removal rate was 29% (5 patients) and the main reason for that was extensor tenosynovitis.

Conclusion: Our study demonstrates that although the functional outcome after using the Pi-plate for complex distal radius fractures is good, there is a significant incidence of extensor tenosynovitis. We recommend that the implant is best used for Type C fractures and be removed electively after fracture union.

Introduction and Aims: The purpose of our study was to assess the efficacy of double osteotomy of the radius and ulna for correction of Madelung’s deformity. Made-lung’s deformity is a congenital alteration of the growth of the ulnar portion of the distal radius resulting in pain, decreased function of the wrist and hand and serious aesthetic disturbances.

Method: Four wrists in four patients with a mean age of 18.3 years were treated for symptomatic increased ulnar and volar inclination of the distal articular surface of the radius. All patients complained of wrist pain. In addition, two of them were dissatisfied with the aesthetic appearance of their wrist and the restricted range of movement. A double osteotomy of the radius and ulna was performed. The ulna was stabilised with a six-hole semi-tubular plate and the radius with a titanium T-plate.

Results: At one-year follow-up: pain relief and cosmetic appearance were satisfactory in all patients. Grip strength improved by 5.3 pounds. Average flexion improved from 63 to 67 degrees and pronation from 59 to 66 degrees. Abduction increased from three to six degrees and adduction from 16 to 21 degrees. Realignment of the wrist was shown radiographically by a change of ulnar inclination and volar inclination of the radius from 35.5 to 24 degrees and 15.5 to 10.5 degrees respectively. There was no evidence of recurrence of the deformity in any of the four wrists.

Conclusion: The initial results with the double osteotomy of the radius and ulna for Madelung’s deformity are promising but need longer follow-up.

Study Design: A randomized, double blind controlled trial.

Objectives: Various studies have examined the therapeutic value of peri-radicular infiltration using treatment agents consisting of local anaesthetic and corticosteroids for radicular pain. The main objective is to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.

Subjects: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomised for a single injection with bupivicaine and methylprednisolone (b+s) or bupivicaine (b) only.

Outcome measures: Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for back pain and leg pain, claudication walking distance and patient’s subjective level of satisfaction of the outcome.

Results: We recruited 43 patients in the b+s group and 43 patients in the b only group. The follow up rate is 100%. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the ODI [p=0.7], change in VAS [back pain, p=0.68; leg pain, p=0.94], change in walking distance [p=0.7]). No statistical difference in the change in VAS score between stenotic group and disc herniation group at 3 months. Further subgroup analysis also showed no difference in the outcome between contained and non-contained herniation group.

Conclusion: Clinical improvement occurs in both groups of patients. Corticosteroid did not provide additional benefit.

Study design: Prospective cohort study.

Objective: Despite wide acceptance of decompression surgery for spinal stenosis, the reported success rates remain variable. Our aim is to investigate the value of various predictors of functional outcome in patients undergoing primary lumbar decompression surgery secondary to degenerative spinal stenosis.

Subjects: Eligible patients who had primary posterior lumbar decompression surgery for degenerative spinal stenosis with follow up for 2 years.

Outcome measures: Oswestry Disability index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS), claudication walking distance and patient’s subjective assessment of the outcome of the surgery.

Results: Ninety-nine patients who had primary lumbar decompression surgery were recruited between July 1994 and December 2001. The follow up rate was 100% at one year and 76% at two years. There is a statistical significant association between duration of symptoms and the change in ODI, change in LBOS, change in VAS and change in walking distance both at one year and two years follow up. One-way analysis of variance also showed that the groups of patients with symptoms less than 33 months have a much better functional outcome at two years follow up. We have not found modified somatic perception score, modified zung depression score and gender to influence the outcome of the surgery.

Conclusion: This study indicates that patients with a prolonged duration of symptoms have a less favourable functional outcome. Patient’s satisfaction is greatest if surgery occurs within 33 months.

Objectives: To assess whether peri-radicular infiltration of corticosteroids has any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Study Design: A double blinded randomised controlled trial

Methods: 81 patients with unilateral radicular pain and failed conservative management were randomised to two groups (B and S). Group B received a single peri-radicular injection with bupivacaine and group S received bupivacaine and methylprednisolone. Both patient and surgeon were blinded to the method of treatment. Statistical analysis involved the use of a Chi Square test.

Outcome measures: 1. Number of additional root blocks required and 2. Requirement for surgery.

Results: At a median follow-up of 20 months (range 12–31 months) follow-up data was available for 70 patients (86%) with 35 patients in each group. There were an equal number of males and females in the groups. In group B, 10 patients required a further root block (29%) compared with 6 patients in group S (17%) [p=0.39]. Similarly 8 patients in group B required subsequent surgery (23%) compared with 3 in group S (9%) [p=0.19]. These differences did not achieve statistical significance probably due to the modest size of this study.

Conclusion: Our findings suggest that adding corticosteroid to bupivacaine nerve root blocks may reduce the need for further root blocks and surgery.

Study Design: A randomised, double-blind controlled trial.

Objectives: To determine the efficacy of corticosteroids in periradicular infiltration for radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.

Summary of background data: Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anaesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomised trial to determine the efficacy of single injection of corticosteroids.

Methods: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomised for single double-blind injection with bupivicaine and methylprednisolone (b+s) or bupivicaine (b) only. Outcome measures include change in Oswestry Disability Index (ODI), change in Visual Analogue Score for back pain and leg pain (VAS), change in walking distance and patient’s subjective level of satisfaction of the outcome. Objective successful clinical outcome is defined as a change in 10% of ODI.

Results: We recruited 37 patients in the b+s group and 38 patients in the b only group. The follow up rate is 100%. 4 patients had early termination of the trial for discectomy and further rootblock. There is no statistically significant difference in the outcome measure between the groups at 3 months (change of the ODI [p=0.6], change in VAS [back pain, p=0.28, leg pain, p=0.95], change in walking distance [p=0.9]). 35% of patients in the b+s group and 55% in the b only group had a successful clinical outcome. Duration of symptoms has a statistically significant negative association with the change in ODI (p=0.03). No prognostic value is found in age, gender, pre-operative Modified Somatic Perception and Modified Zung Depression score.

Conclusion: Clinical improvement occurs in both groups of patients. However, corticosteroids do not provide additional benefit.