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.

Infections in spine surgery are relatively common and devastating complications, a significant burden to the patient and the healthcare system. Usually, the treatment of SSIs consists of aggressive and prolonged antibiotic therapy, multiple debridements, and in chronic cases, hardware removal. Infections are correlated with worse subjective outcomes and even higher mortality. Depending on the type of spine surgery, the infection rate has been reported to be as higher as 20%. Recently silver-coated implants have been introduced in spine surgery to reduce the incidence of post-operative infections and to improve implant survivorship. The aim of the present study is to evaluate complications and outcomes in patients treated with silver-coated implants because of spine infection. All consecutive patients who had spine stabilization with a silver-coated implant from 2018 to 2021 were screened for inclusion in the study. Inclusion criteria were: (1) six months of minimum follow-up; (2) previous surgical site infection; hematogenous spondylodiscitis requiring surgical stabilization. Demographic and surgical information were obtained via chart review, all the device-related complications and the reoperation rate were also reported. A total of 57 patients were included in the present study. The mean age was 63.4 years, and there were 36 (63%) males and 21 (37%) females. Among the included cases, 57% were SSIs, 33% were spondylodiscitis, and 9% were hardware mobilization. Comorbidities such as diabetes mellitus, obesity, smoke, and oncological history were significant risk factors. In addition, the organisms cultured were Staphylococcus species in most of the cases. At six months of follow-up, 40% of patients were considered free from infection, while 20% needed multiple surgeries. The present research showed satisfactory results of silver-coated implants for the treatment of spine infection

Numerous prediction tools are available for estimating postoperative risk following spine surgery. External validation studies have shown mixed results. We present the development, validation, and comparative evaluation of novel tool (NZSpine) for modelling risk of complications within 30 days of spine surgery. Data was gathered retrospectively from medical records of patients who underwent spine surgery at Waikato Hospital between January 2019 and December 2020 (n = 488). Variables were selected a priori based on previous evidence and clinical judgement. Postoperative adverse events were classified objectively using the Comprehensive Complication Index. Models were constructed for the occurrence of any complication and significant complications (based on CCI >26). Performance and clinical utility of the novel model was compared against SpineSage (. https://depts.washington.edu/spinersk/. ), an extant online tool which we have shown in unpublished work to be valid in our local population. Overall complication rate was 34%. In the multivariate model, higher age, increased surgical invasiveness and the presence of preoperative anemia were most strongly predictive of any postoperative complication (OR = 1.03, 1.09, 2.1 respectively, p <0.001), whereas the occurrence of a major postoperative complication (CCI >26) was most strongly associated with the presence of respiratory disease (OR = 2.82, p <0.001). Internal validation using the bootstrapped models showed the model was robust, with an AUC of 0.73. Using sensitivity analysis, 80% of the model's predictions were correct. By comparison SpineSage had an AUC of 0.71, and in decision curve analysis the novel model showed greater expected benefit at all thresholds of risk. NZSpine is a novel risk assessment tool for patients undergoing acute and elective spine surgery and may help inform clinicians and patients of their prognosis. Use of an objective tool may help to provide uniformity between DHBs when completing the “clinician assessment of risk” section of the national prioritization tool

Aims. With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic. Methods. A prospective observational study was conducted from eight spinal centres for the first month of operating following restoration of elective spine surgery in each individual unit. Primary outcome measure was the 30-day postoperative COVID-19 infection rate. Secondary outcomes analyzed were the 30-day mortality rate, surgical adverse events, medical complications, and length of inpatient stay. Results. In all, 257 patients (128 males) with a median age of 54 years (2 to 88) formed the study cohort. The mean number of procedures performed from each unit was 32 (16 to 101), with 118 procedures (46%) done as category three prioritization level. The majority of patients (87%) were low-medium “risk stratification” category and the mean length of hospital stay was 5.2 days. None of the patients were diagnosed with COVID-19 infection, nor was there any mortality related to COVID-19 during the 30-day follow-up period, with 25 patients (10%) having been tested for symptoms. Overall, 32 patients (12%) developed a total of 34 complications, with the majority (19/34) being grade 1 to 2 Clavien-Dindo classification of surgical complications. No patient required postoperative care in an intensive care setting for any unexpected complication. Conclusion. This study shows that safe and effective planned spinal surgical services can be restored avoiding viral transmission, with diligent adherence to national guidelines and COVID-19-secure pathways tailored according to the resources of the individual spinal units. Cite this article: Bone Jt Open 2021;2(12):1096–1101

Spine surgery is common and costly. Researchers and policy makers believe that utilization of spine surgery in the US is significantly higher than in other industrialized countries. Although within-country variation in spine surgery utilization is well studied, there has been little exploration of variation in spine surgery between countries. We used population level administrative data from Ontario (years 2011–2015) and New York (2011–2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared rates of decompression and fusion surgery (procedures per-10,000 population per-year) in Ontario and New York for all procedures, emergent procedures alone, and elective procedures and after stratifying by patient age. Patients in Ontario were older than patients in New York for decompression (mean age 58.8 vs. 51.3 years, P<.001) and fusion (58.1 vs. 54.9, P<.001). A smaller percentage of hospitals in Ontario performed decompression or fusion compared to New York (decompression, 26.1% in Ontario vs 54.9% in New York: fusion 15.2% vs 56.7%, both P<.001). Overall, utilization of spine surgery in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 18 per-10,000 per-year (P<.001). Ontario-New York differences in utilization were small for emergent cases (2 per-10,000 in Ontario vs. 2.8 in New York, P<.001), but large for elective cases (4.6 vs 15.2, P<.001). In analyses stratified by surgical subtype, differences in utilization of decompression in New York and Ontario were relatively modest (2.4 vs 3.1, P<.001), while utilization of fusion was approximately 400% higher in New York than Ontario (15.7 vs 3.5, P<.001). Further analysis demonstrated that the New York-Ontario difference in utilization was substantially larger among younger patients and smaller for older patients. For example, utilization of spine procedures in New York was 340% greater than Ontario for patients less-than 50 years of age (11.7 vs 3.4), but only 25% greater in patients age 80 and above (10 vs 12.6). After adjusting for patient demographics, hospital LOS and surgical urgency, differences in mortality in Ontario and New York were not significant for either decompression or fusion. In adjusted analyses differences in hospital LOS were slightly greater for decompression in Ontario, but similar for fusion and readmission rates in Ontario were significantly lower than in New York. In conclusion, we found significantly lower utilization of spine surgery in Ontario when compared to New York. The difference in utilization was attributable to less elective fusion surgery, primarily in younger (i.e. non-Medicare) patients. These findings can serve inform broader spine surgery policy reforms in both jurisdictions

Introduction. The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires. Materials and Methods. Whilst positioned in the supine or lateral position, a routine supine anterior lumbar interbody fusion (ALIF), and/or antero-lateral ALIF (AL-ALIF) and/or lateral lateral interbody fusion (LLIF) is performed. The patient is then turned prone or kept in the single lateral position (SPL) for insertion of the posterior screws performed under robotic guidance. Intraoperative CT scan 3D images captured then are sent to the Robotic software platform for planning of the screw trajectories and finally use again at the end of the procedure to confirm screw accuracy. We identified 34 consecutive patients from October 2019 to January 2020 who underwent robotic assisted spine surgery. The demographic, intraoperative, and perioperative data of all these patients were reviewed and presented. Results. Of the 34 patients, 65 levels were treated in total using 204 screws. Of the 21 patients (60%) who underwent single-level fixation, 14 of them (67%) were treated at the L5/S1 level, 3 at L3/L4, 3 at L4/L5 and 1 at L2/L3 level. The remaining 13 patients (40%) underwent multi-level fixation, of which 4 were adult scoliosis. 15 underwent a supine ALIF approach, 1 underwent AL-ALIF, 8 patients underwent combined LLIF and AL-ALIF approach in a lateral decubitus, whilst 9 underwent pure LLIF approach (of which 3 patients were in the single position lateral) and one patient had previous TLIF surgery. The average estimated blood loss was 60 cc. The average planning time was 10 min and the average duration of surgery was 50 min. The average patient age was 54 years and 64% (22/34) were male. The average BMI was 28.1 kg/m. 2. There were no re-interventions due to complications or mal positioned screws. Conclusion. Minimally invasive spine surgery using robot-assisted navigation yields an improved level of accuracy, decreased radiation exposure, minimal muscle disruption, decreased blood loss, shorter operating theatre time, length of stay, and lower complication rates. Further follow-up of the patients treated will help compare the clinical outcomes with other techniques

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

Frailty has been shown to be a risk predictor for peri-operative adverse events (AEs) in patients undergoing various type of spine surgery. However, its relationship with Patient Related Outcome Measures (PROMS) remains unknown. The primary objective of this study was to determine the impact of frailty on PROMS in patients undergoing surgery for thoraco-lumbar degenerative conditions. The secondary objective was to determine the association between frailty and baseline PROMS. This is a retrospective study of a prospective cohort of patients >55 years old who underwent surgery between 2012 and 2018. Patient data and PROMS (EQ-5D, SF-12, ODI, back and leg pain NRS) were extracted from the Canadian Spine Outcomes and Research Network registry for a single academic centre. Frailty was retrospectively calculated using the modified frailty index (mFI) and patient were classified as frail, pre-frail and non-frail. Patient characteristics and outcomes were analyzed using ANOVA or Kruskal-Wallis test for continuous variables and Chi square or Fisher's exact test for proportions. A generalized estimating equations (GEEs) regression model was used to assess the association between patients' baseline frailty status and PROMs measures at three and 12 months. 293 patients were included with a mean age of 67 ± 7 years. Twenty-two percent of the patients (n= 65) were frail, 59 % (n=172) were pre-frail and 19% (n=56) were non-frail. At baseline, the three groups had similar PROMS, except for the PCS which was worse in the frail group (mean difference [95% CI], −4.9 [−8.6;-1.1], p= 0.0083). The improvement in the EQ-5D, PCS, MCS, ODI, back and leg pain NRS scores was not significantly different between the three groups (p> 0.05). The was no difference in the evolution of the PROMS at three and 12 months between the three groups (p> 0.05). Although frailty is a known predictor of AEs, it does not predict worse PROMS after spine surgery in that population. At baseline, non-frail, pre-frail and frail patients have similar PROMS

Introduction and Objective. Over the past few years, a reorganization of the educational pathways has been promoted with the purpose of optimizing the acquisition of competences and their assessment, so as to reduce the risks to both health care professionals and end users. Virtual reality (VR) has been repeatedly tested, initially as a positive reinforcement for more traditional educational pathways and, more recently, as their potential substitute. The aim of this study was to demonstrate the potentiality of VR simulation training in spine surgery. Materials and Methods. The VR simulator reproduced the lateral lumbar access to the spine. The simulation included a tutorial, the preoperative settings, and the surgical session with different levels of procedural complexity. A total of 10 users were recruited for this study: 3 senior surgeons (group A) and 7 orthopedic residents or junior orthopedic surgeons (group B). Each user completed the simulation twice. Results. The user's age or previous experience with VR technology did not show any relevance. On average, the entire simulation was completed in 24 minutes and 36 seconds. Group B showed an improvement between the 2 attempts in both sessions, the preoperative settings and the surgical simulation. The number of major errors dropped from an average of 5.2 to 1.8 and from an average of 4 (1–6) to 1.4, respectively. The simulation was never interrupted because of technical bugs or adverse effects related to the technology. Conclusions. VR-based training pathways might promote a high standard of care. Our preliminary experience suggests an effective implementation of the traditional coaching process

Abstract. Aim. With resumption of elective spine surgery services following the first wave of COVID-19 pandemic, we conducted a multi-centre BASS collaborative study to examine the clinical outcomes of surgeries. Methods. Prospective data was collected from eight spinal centres in the first month of operating following restoration of elective spine surgery following the first wave. Primary outcomes measures were the 30-day mortality rate and postoperative Covid-19 infection rate. Secondary outcomes analysed were the surgical, medical adverse events and length of inpatient stay. Results. 257 patients (128 Male) with an age range of 2–88 years formed the study cohort. The average workload from each unit was 32(range 16–101) with 118 procedures (46%) done as category 3 prioritisation level (Procedures performed in < 3 month). 87% of patients were low-medium “risk stratification” category. 195 patients (75.8%) isolated for two weeks preoperatively and all but four patients had COVID-19 negative test prior to surgery. None of the patients were diagnosed with COVID-19 infection nor was any mortality related to COVID-19 in the 30 day follow up period, with 25 patients having been tested for symptoms. 32 patients (12%) developed a total of 34 complications with 19/34 being grade 1–2 Clavien-Dindo classification of surgical complications. Median LOS 5.2 days and 78.4 % patients stayed less than a week. Conclusions. As per our study safe and effective planned spinal surgical services can be restored avoiding viral transmission, with adherence to national guidelines and COVID-secure pathways tailored according to the resources of the individual spinal units

Introduction and Aims: Although PD has characteristic findings and stages of progression, neither the nature of operative spine problems occurring in patients with PD, nor their peri-operative complications, have been presented previously. Method: In this retrospective observational case series, we describe the nature of operative spine problems in patients with Parkinson’s disease (PD), and evaluate the incidence and types of peri-operative complications in spine surgery for patients with PD. A retrospective chart review was performed on 24 consecutive PD patients undergoing spine surgery in a six-year span at one institution. Nineteen were first surgeries, and five were first seen as failed back syndrome from surgery done elsewhere. Results: The mean patient age was 69 years. Spinal stenosis (10 patients) and cervical myelopathy (4 patients) were the predominant pre-operative diagnoses for the primary surgeries, with three patients operated upon for kyphoscoliosis (16%) and two for other conditions. Minor or transient complications were common, including delirium, arrhythmia, deep vein thrombosis, and dural tear; there were also two significant PD-specific complications, including aspiration pneumonia and global motor paresis post-operatively. Four of 19 primary cases were revised for recurrent stenosis (two patients) or pseudarthrosis (two patients). The overall number of poor patient-reported outcomes was only two of 14 primary cases (five patients had inadequate outcome measures) and zero of seven revisions (two had inadequate outcome measures), at a mean follow-up of 19 months. Conclusion: Symptoms and functional deficits of spinal disease were often masked by PD, posing diagnostic difficulty. However, outcomes and complications of spine surgery were similar to those of non-PD patients at the same institution. Spine symptoms improved concomitantly with successful surgery unless the PD progressed or significant complications ensued

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

Aims. Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. Methods. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. Results. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. Conclusion. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery. Cite this article: Bone Joint J 2023;105-B(4):422–430

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration

Aims. During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients. Patients and Methods. All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (. sd. 20.4) and there were 104 female patients. Results. Sonication cultures were positive in 75 cases (45.2%). Hardware failure was the most common indication for revision surgery and revealed a positive sonication culture in 26/75 cases (35%) followed by adjacent segment disease (ASD) in 23/75 cases (30%). Cutibacterium acnes and Staphylococcus epidermidis were the most commonly isolated microorganisms, observed in 45% and 31% of cases, respectively. C. acnes was isolated in 65.2% of cases when the indication for revision surgery was ASD. Conclusion. Infection must always be considered as a possibility in the setting of spinal revision surgery, especially in the case of hardware failure, regardless of the lack of clinical signs. Sonication should be routinely used to isolate microorganisms adherent to implants. Cite this article: Bone Joint J 2019;101-B:621–624

Mental disorders in particular depression and anxiety have been reported to be prevalent among patients with spinal pathologies. Goal of the current study was to analyze the relationship of Zung pre- and post-op score to other PROs and length of stay. Secondary outcomes included revision surgery and post-operative infections. Data from the international multicenter prospective spine degenerative surgery data repository, DegenPRO v1.1 (AO Spine Knowledge Forum Degenerative) were utilized. Patients undergoing cervical or lumbar procedure were included. Patient's demographics, Charlson Comorbidity Index, surgical information, Zung score, NDI, pain related PROs and EQ-5D, and complications at surgery and at various post-op time periods. Except for hospital duration, data were analyzed, using multivariable mixed linear models. A robust linear regression model was used to assess the association between Zung score and hospital duration. All models were adjusted for gender and age. 42 patients had Zung score administered. Among those patients 22 (52%) were within normal range, 18 (43%) were mildly and 2 (5%) severely depressed. 62% of the patients had a lumbar pathology with fusion procedures being the most common. Median EQ-5D (3L) score at surgery was significantly higher (0.7, IQR: 0.4-0.7) for patients within normal range than for those with mild (0.4, IGR: 0.3-0.7) or severe depression (0.3, IQR: 0.3-0.3, p-value: 0.05). Compared to patients within normal Zung range, mixed models, indicated lower EQ-5D (3L) score values and higher values for neck and arm pain at surgery with both PROs and EQ-5D (3L) improving in patients with depression over the follow-up time. No association was found between Zung score and hospital length of stay. The initial analysis showed that 43% of the patients were mildly depressed and mainly male patients. Zung score was correlated with post-operative improvements in EQ-5D and arm and neck pain PROs

Post-operative infection is a serious complication of spine surgery and can contribute to the strain on the healthcare system's resources. The purpose of this study is to determine what factors affect the risk of developing postoperative infection. We hypothesize that female gender, smoking, diabetes, having thoracolumbar procedures, having a neurological deficit, increased age, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, blood loss, number of operative levels, operative time and undergoing non-elective surgery will increase the patients' risk of developing a post-operative infection. A retrospective review of prospectively collected data within the Canadian Spine Outcome and Research Network (CSORN) was conducted. Data was analyzed using IBM-SPSS. Multivariable logistical regression analysis was conducted (odds ratios) to determine any association between the outcome and independent factors. Significance level was p < 0.05. There were 7747 patients identified from the registry that had completed at least 12 weeks of follow up. There were 199 infections recorded representing a 2.6% risk of infection. There were no association found between the risk of developing a post operative infection and gender, smoking, diabetes, having thoracolumbar procedures, having a neurological deficit, ASA score, blood loss, number of operative levels and undergoing non-elective surgery. The following were associated with an increased risk of developing a post operative infection: Older age (adjusted OR=1.021, 95% CI=1.005–1.038, p < 0 .05), having an elevated BMI (adjusted OR=1.042, 95% CI=1.013–1.072, p < 0 .005), longer operative time (adjusted OR=1.002, 95% CI=1.001–1.004, p < 0 .001). There is a 2.6% overall rate of post-operative spine infection across 20 Canadian centres. The factors that were associated with an increased risk of developing a post operative-infection were older age, increased BMI and longer operative time. This study establishes a benchmark against which the effectiveness of future interventions to reduce infection can be compared

Background:. Following lumbar spine surgery patients with a high BMI appear to have increased post-operative complications including surgical site infections (SSI), urinary complications, increased anaesthetic/operative time and a greater need for post-operative blood transfusion. There is no current evidence, however, analysing the effect of BMI on functional outcome. Purpose:. We aimed to analyse the effect of BMI on functional outcome following lumbar spine surgery. Study Design:. Retrospective Cohort Study. Patient Sample:. 131. Outcome Measures:. Outcome measures included mean post-operative Oswestry Disability Index (ODI) at six and twelve months, the incidence of SSI, mean operative time and the requirement for post-operative blood transfusion. Methods:. Patients that underwent lumbar spinal surgery between September 2010 and November 2013 were identified retrospectively and categorised into discectomy, decompression, fusion and revision is created. A BMI threshold of 30 was used to group patients as non-obese or obese. Univariate analysis was used to compare the effect of BMI on the above outcome measures. Results:. Post-operative complication rates were higher in the obese group in each category. However, there was no significant difference in the post-operative ODI at six ad twelve months post-operatively. Conclusions:. Increased BMI is related to increased post-operative complications but is not associated with a poorer functional outcome in the short to mid-term

Aims. Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date. Methods. Patients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication. Results. A total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age > 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment. Conclusion. Cases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery. Cite this article: Bone Jt Open 2023;4(11):832–838

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

Background/Purpose of study. The increasing aging of the population will see a growing number of patients presenting for spine surgery with appropriate indications but numerous medical comorbidities. This complicates decision-making, requiring that the likely benefit of surgery (outcome) be carefully weighed up against the potential risk (complications). We assessed the influence of comorbidity on the risks and benefits of spine surgery. Methods. 3′699 patients with degenerative lumbar disorders, undergoing surgery with the goal of pain relief, completed the multidimensional Core Outcome Measures Index (COMI; scored 0–10) before and 12 months after surgery. At 12mo they also rated the global treatment outcome and their satisfaction. Using the Eurospine Spine Tango Registry, surgeons documented surgical details, American Society of Anesthesiologists (ASA) scores and surgical/general complications. Results. 29.8% patients were rated ASA1 (normal healthy), 44.8% ASA2 (mild/moderate systemic disease), 25.0% ASA3 (severe) and 0.4% ASA4 (life-threatening). In going from ASA1 to ASA3 (ASA4 group too small), surgical complications increased significantly from 3.6% to 11.1% and general complications increased from 2.3% to 12.6%; 12-month outcomes showed a corresponding decline, with a good global outcome being reported by 78% ASA1 patients, 76% ASA2, and 68% ASA3. Satisfaction with treatment was 87%, 85%, and 79%, respectively and reduction in COMI, 4.2±2.9, 3.7±3.0, and 3.3±3.0 points, respectively. Conclusion. The negative impact of comorbidity on the outcome of spine surgery has not been well investigated/quantified to date. The ASA grade may be helpful in producing algorithms for decision-making and preoperative counselling regarding the corresponding risks and benefits of surgery. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders. Methods. We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected). Results. There were 9.4% surgical complications (most commonly dural tear, neurological sequelae, haematoma, infection) and 6.5 % general complications (most commonly cardiovascular, urinary, pulmonary, liver/GI). In the multivariable models, previous surgery significantly increased the odds of having a surgical complication (OR 1.148, 95%CI 1.051–1.253; p=0.002) and a medical complication (OR 1.185, 95%CI 1.074–1.307; p=0.001) i.e., for each previous surgery, the odds of a complication increased by 15% and 19%, respectively. Conclusion. We demonstrated a significant dose-response effect of previous surgery on the risk of incurring a complication during subsequent spine surgery. The results can be used by the surgeon when assessing the risk/benefit ratio of further surgery, for informing and consenting the patient. No conflicts of interest. No funding obtained

Recently, there is ongoing evidence regarding rapid recovery after orthopaedic surgery, with advantages for the patient relative to post operative pain, complications and functional recovery. The aim of this study is to present our experience in rapid recovery for adolescent idiopathic scoliosis in the last 2 years.

Retrospective study of 36 patients with adolescent idiopathic scoliosis, (age range 11 to 18 years) treated with spinal thoraco-lumbar posterior fusion with rapid post-operative recovery, compared with a similar group, treated with traditional protocol.

We found a statistically significant difference in terms of length-of-stay, patient-controlled-analgesia and use of oppioid and post operative blood transfusions. There was no difference in post operative infection rate.

Our experience shows better functional recovery, satisfactory controlled analgesia and reduction in costs of hospitalization with the use of ERAS protocols.

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery. Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature. Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants. 40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively. Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication

Introduction: It is very common in spine surgery to transfuse substantial amounts of homologous blood. The danger of spreading infectious diseases (HIV, HBV etc.) as well as possible side- effects of multiple transfusions (haemolysis, anaphylaxia, etc.) has created the necessity of finding methods to minimize the amount of homologous blood transfusions. One of these methods is the use of systems for autotransfusion of the patient’s drained blood. Purpose: Evaluation of the advantages of the use of postoperative autotransfusion systems is spine surgery. Methods: 26 patients were evaluated, from November 2002 until May 2003, who underwent posterior spinal fusion and to whom postoperative autotransfusion was used. The patients’ group consisted of 19 women and 7 men aged from 14–75 years old (aver.23.8 years of age). We recorded the preoperative haematocrit value, the amount of homologous blood transfused intra- and postoperatively, the amount of autologous blood transfused as well as the haematocrit values at the 1st, 2nd, and 5th postoperative day. Moreover all the patients were observed postoperatively for possible complications relevant to autotransfusion. Results: 70% of the patients did not require postoperative transfusion with homologous blood. We observed allergic reactions in 4 patients and fever in 3 patients. These findings were not directly correlated to autotrans-fusion, however the autotransfusion was interrupted. There were no major complications. The above mentioned results are considered to be encouraging for further us and study of postoperative autotransfusion systems in spine surgery

Male retrograde ejaculation is a well-documented but rare complication of anterior approach lumbar spine surgery. Retraction of the soft tissues which encase the superior hypogastric plexus leads to dysfunction of the sympathetic control of the bladder neck sphincter. We postulated that similar nerve root dysfunction in females may lead to bladder problems and sexual dysfunction. The Female Sexual Function Index Questionnaire was sent to 20 consecutive women who had undergone anterior spinal surgery by the senior author (GM). Questionnaires were returned by 11 of the 20 subjects. 6 had undergone disc replacement surgery and 5 anterior lumbar interbody fusion. All procedures used an anterior retroperitoneal approach. The age range was 20 to 49 years (mean 40.2 years). There were no immediate peri-operative complications. The mean time since surgery was 4.9 years (range 3.1 to 5.8 years). The Female Sexual Function Index is a validated questionnaire used internationally as the gold standard measure of sexual dysfunction in women. Urinary frequency and incontinence were also recorded. 9 women (82%) described a degree of post-operative sexual dysfunction with 7 (64%) recording urinary frequency and urge incontinence. Although some sexual dysfunction may be expected from pre-existing conditions, we highlight this complication following anterior lumbar spine surgery in females. We plan to further investigate its incidence and possible resolution of symptoms after a prolonged period in a larger case series

Adverse events (AEs) following spine surgery are very common. It is important to monitor the incidence of AEs to ensure that appropriate practices are implemented to minimise AEs and improve patient outcomes. The Spine Adverse Events Severity System (SAVES) is a validated AE recording tool specifically designed for spine surgery and the Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) is a similar tool intended for general orthopaedic surgery. The main objective was to prospectively collect AE data from spine surgery patients using SAVES and OrthoSAVES and compare their viability and applicability for use. The longterm objective is to enhance patient safety by tracking AEs with a view towards potentially changing future healthcare practices to eliminate the risk factors for AEs. For a 10-week period in June-September 2015, three spine surgeons used SAVES to record AEs experienced by any elective spine surgery patients. In addition, a trained independent clinical reviewer with access to electronic records, medical charts, and allied health professionals (e.g. nurses, physioterhapists) used SAVES and OrthoSAVES to record AEs for the same patients. At discharge, the SAVES forms from the surgeons and SAVES and OrthoSAVES forms from the independent reviewer were collected and all AEs were recorded in a database. In 48 patients, the independent reviewer recorded a total of 45 AEs (4 intra-operative, 41 post-operative), compared to the surgeons who recorded a total of 8 AEs (2 intra-operative, 6 post-operative) (P2) were recorded by both the independent reviewer and surgeons. OrthoSAVES had the capacity to directly record 3 additional AEs that had to be included in the “Other” section on SAVES. SAVES and OrthoSAVES are valuable tools for recording AEs. Use of SAVES and OrthoSAVES has the potential to enhance patient care and safety by ensuring AEs are followed by the surgeon during their in-hospital stay and prior to discharge. Independent reviewers are more effective at capturing AEs following spine surgery, and thus, could be recruited in order to capture more AEs and maximise different complication diagnoses in alignment with proposed diagnosis-based funding models. The next step is to analyse AE data identified by the hospital discharge abstract to determine whether retrospective administrative coding can adequately record AEs compared to prospectively-collected AE data with SAVES/OrthoSAVES

In orthopaedic spine surgery pedicle screw systems are used for stabilisation of the spine after injuries or disorders. With an percutaneous operation method surgeons are faced with huge challenges compared to an open surgery, but it's less traumatic and the patient benefits with a faster rehabilitation and less traumatic injuries. The screw positions and the required rod dimensions for the stabilising connection between the screws are hard to define without an open view on the operating field. Because of these facts a new smart device based system for rod shape determination was invented. Therefore, an application was developed, which integrates a localiser module to get the position data of the pedicle screws, with help of rigid bodies placed on top of the pedicle screws down-tubes. An algorithm was developed to choose the best fitting rod to connect the pedicle screws with help of calculating the rod length and the rod radius. The system was tested in a test scenario where four pedicle screws were drilled into a wooden plate. The positions of the screws were adjusted to fit a curved and a straight rod. In the test scenario the application chose always the rod correctly

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

Purpose. To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome. Methods. Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A. In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented. Results. Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline. Conclusion. Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term. Ethics - none, Interest –none

Introduction The frequency of spine surgery in the elderly continues to increase in parallel with the overall aging of the population. The main goal of this study was to determine if age is a risk factor for major complications in spine surgery. In addition, other co-morbidities and the relationship with age and potential for major complications were explored. Methods All adult patients undergoing spine surgery at our center over a four-year period were included in this study, for a total of 1937 patients (605 age 18 – 39; 1001 age 40–64, 331 age 65 and over). One independent observer abstracted baseline medical histories and co-morbidities as well as post-operative complications. Major risk factors explored included history of cardiac, cancer, smoking, diabetes, substance abuse, obesity, respiratory problems, previous infections and hypercholesterolemia. Details of surgical procedure, including type of surgery, duration of surgery and blood loss were also captured. Major complications were defined as death, CVA, embolism, pneumonia and deep wound infections. Patients ranged in age from 18 years to 91 (average age 48 years) and 41% were males. Thirty percent of the population was deformity patients, 49% degenerative patients and the remaining 21% had various other spine problems. Thirty-five percent of the patients underwent a combined anterior posterior procedure, 13% anterior alone and 34% posterior alone. Statistical analysis included descriptive summary, vicariate correlation to assess individual risk factors (university analysis) and multivariate regression. Results The overall major complication rate was 2.1% (40 patients). There were no intra- or post-operative deaths. Major complications included 7 CVA (0.4%), 2 embolisms (0.1%), 3 deep wound infections (0.2%) and 28 pneumonia (1.4). For patients age 65 or older,. Overall, 61% of the patients had at least one of the major risk factors. The number of major risk factors increased with increased age. The percent of patients with any given risk factor also increased with age. When no other factors were taken into account (such as co-morbidities), there was an increased occurrence of a major complication (any one), pneumonia and infection with increased age at time of surgery. In order to differentiate the effect due to age and due to co-morbidities (which increased with age), multivariate regression was utilized. For the occurrence of any major complication, the presence of respiratory problems and previous infection were both more influential than age. Furthermore, when the effects of these two risk factors were controlled for, there no longer was an effect due to age. Discussion Older patients did not have an increased rate of major complications when compared to younger patients with similar respirator and infection history profiles

Incidental durotomy is a relatively common occurrence during spinal surgery. There remains significant concern about this complication despite reports of good associated clinical outcomes. There have been few large clinical series on the subject. Durotomy can cause postural headaches, nausea, vomiting, dizziness, photophobia, tinnitus, and vertigo and even severe meningitis and death. Traditional management includes bed rest for up to 7 days to eliminate traction and reduce hydrostatic pressure during the healing process. Methods: All patients who had spine surgery in our institute by the same surgeon during the last three years, enrolled into the study. Patients who did not have canal exploration as part of their procedure, were excluded. Once durotomy had been recognized, immediate repair of the dura was done. An intra-operative Val-Salva maneuver was preformed and once no CSF leak was observed, the wound was tightly closed and no drains were left. In cases where no access to the leaking durotomy was possible, or the Val-Salva maneuver ended with CSF leak, a combination of fibrin glue and hemostatic materials were used to cover the dura. On the first postoperative day the dressing was carefully inspected for any secretions. Patients who had their dressing dry and clean were allowed to get out of the bed with regular, unlimited, postoperative course. Patients who had a wet dressing due to CSF leak were instructed to stay in bed and a CD catheter was considered. Results: There were 381 patients in the study group, 281 had instrumented procedures combined with canal decompression and 110 had decompression only. Incidental durotomy occured in 13 patients (3.4%); complete closure of the dura was possible in 10 while the rest had the fibrin glue sealing procedure. From the 3 patients, only one had a CD insertion due to continuous CSF leak, developed gram-negative meningitis and died. All accept the one patient had regular postoperative mobilization without any late CSF discharge or other related complications. Conclusions: Although rare, incidental durotomy is one of the upsetting complications in spine surgery. No fixed, well-established protocol exists and the post-operative recommendation varies among surgeons. Our experience shows that, based upon the described algorithm, one can safely mange patients who had incidental durotomy with a regular post-operative course

Background. While the biomechanical properties of trans-pedicular screws have proven to be superior in the lumbar spine, little is known concerning pullout strength of trans-pedicle screws in comparison to different distal terminal constructs like sublaminar hooks alone, trans pedicular screws with sublaminar hooks and clow hooks alone in the thoracolumbar spine surgery. In vitro biomechanical pullout testing was performed to evaluate the axial pullout strength of four different distal terminal constructs in thoracolumbar spine surgery. Methods. 32 fresh-frozen lamb spines were used. The lamb spines were divided into four groups, each group is composed of eight lamb spine cadavers with a different distal fixation pattern was used to terminate the construct at L1. (Group 1) trans-pedicular screws alone, (Group 2) sublaminar hooks alone, (Group 3) trans-pedicular screws augmented with a sublaminar hooks via a domino connector and (Group 4) clow hooks alone. Results. The average pullout strength of group 1 was 927N, group2 was 626N, group 3 was 988N and group 4 was 972N. Group 3 and 4 showed the most significant pullout forces when compared to group 1 and group 2. However Group 3 and group 4 didn't show any significant statistical difference when compared to each others. Conclusion. Our study thus suggests that the strongest construct that may reduce the pullout phenomina in the distal fixation constructs are the trans-pedicular screw with laminar hooks. It is strongly advised to be used in osteoporotic bones and in conditions where pullout strength is required to be enhanced. But farther prospective clinical studies are needed to clearly demonstrate the beneficial effect of a trans-pedicular screw augmented with a laminar hooks in reducing the risk of distal instrumentation pullout. Level of Evidence. Level 5. Disclosure. The authors declare that no conflict of interests were associated with the present study

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. 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. Methods. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. Results. This investigation included 739,474 spinal surgeries and 739,215 hospitalizations in Japan. There was an average annual increase of 4.6% in the number of spinal surgeries. Scheduled hospitalizations increased by 3.7% per year while unscheduled hospitalizations increased by 11.8% per year. In-hours surgeries increased by 4.5% per year while after-hours surgeries increased by 9.9% per year. Complication rates and costs increased for both after-hours surgery and unscheduled hospitalizations, in comparison to their respective counterparts of in-hours surgery and scheduled hospitalizations. Conclusion. This study provides important insights for those interested in improving spine care in an ageing society. The swift surge in after-hours spinal surgeries and unscheduled hospitalizations highlights that the medical needs of an increasing number of patients due to an ageing society are outpacing the capacity of existing medical resources. Cite this article: Bone Jt Open 2024;5(8):662–670

NHS Patients can wait up to 15 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?. In a prospective study, 105 patients listed for elective lumbar spine surgery at a district general hospital If the MRI scan is over 6 months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted. 44% Discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. 14% discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, prolapse at a new level, progressive modic changes and compression at other levels. We do not support the fact that patients may have to wait upto 18 months before having elective spinal surgery. However, we found that significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient that had been listed for fusion alone got better. Due to changes seen on the second MRI scan, 1 in 6 operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

Objective: NHS Patients can wait up to 18 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?. Design: A Prospective study. Subjects: 105 patients listed for elective lumbar spine surgery at a district general hospital. Outcome Measures: If the MRI scan is over six months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted. Results: Forty-four percent discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. Fourteen percent discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, pro-lapse at a new level, progressive modic changes and compression at different levels. Conclusions: We do not support the fact that patients may have to wait up to 18 months before having elective spinal surgery. However, a significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient who had been listed for fusion alone got better. Due to changes seen on the second MRI scan, one in six operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

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

Background. Recent years have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires replacing traditional surgeon-based assessments. The assessment of “complications” — loosely defined as new/unexpected problems arising as a result of surgery — has not enjoyed this same enlightened approach. Methods. Patients with lumbar degenerative disorders operated with the goal of pain relief, completed a questionnaire 1 year post-operatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point adjectival scale. Global outcome of surgery and satisfaction were rated on 5-point Likert scales. Results. Of 2946 (92% compliance) patients completing the questionnaire, 861 (29%) reported complications, most commonly sensory disturbances (37% of those with complications) or ongoing pain (22%), followed by motor problems (9%), pain plus sensory disturbances (8%), and problems with wound healing (6%). The corresponding “bothersomeness” ratings for these were: 1% not at all, 23% slightly, 26% moderately, 31% very, and 19% extremely bothersome. Bothersomeness was significantly correlated with global outcome (Rho=0.51, p<0.0001) and satisfaction (Rho=0.43, p<0.0001). A good global outcome was reported by 80% of patients with no complications and only 58% of those with complications; satisfaction was 88% and 72%, respectively. Conclusion. Most complications reported by the patient are perceived to be at least moderately bothersome and are hence not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspective — not least to better understand the reasons for poor outcome and dissatisfaction with treatment. Conflicts of Interest. None. Source of Funding. None

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.

Introduction: The lumbosacral medulla is vascularized by the Adamkiewicz arteria which irrigates the anterior spinal arteria. Occlusion or section of the Adamkiewicz arteria may induce an ischemia of the medulla during anterior or transforaminal spine surgery. An angiography allows to determine the exact topography of this artery. The purpose of this study was to describe its preoperative topography and to analyze the impact of angiography on the surgical strategy. Methods: In this retrospective study, 100 preoperative medullar angiographies, performed by a vascular radiologist between january 1998 and august 2007, were reviewed. Surgical indications were: 50 vertebrectomies in tumors, 20 anterior fusions in dorsolumbar fractures, 10 anterior fusions in malunions, 10 anterior releases in scoliosis, 3 transpedicular osteotomies, 7 disc hernias (T7-L4). The level and the side of foraminal entrance of the Adamkiewicz arteria and collateral arterias irrigating the anterior spinal arteria were analyzed. We looked for the occurence of postoperative ischemic signs of the medulla. Modifications of surgical planning because of Adamkiewicz’ arteria topography were noted. The possibilities of preoperative tumor embolisation were analyzed. Results: The Adamkiewicz arteria was always localized between T8 and L3. It was present at the foraminal levels L1/L2 or L2/L3 in 48% of the cases. The left side was concerned in 65% of the cases. A modification of the surgical strategy was noted in 16% of the cases: 12 side changements of operative approach, 4 contra-indications for anterior surgery. An ischemic syndrome of the anterior lumbosacral medulla were not found. In the group of tumors, the preoperative angiography allowed to perform a selective embolisation of tumor vessels in 80% of the cases. In all other cases, the tumor vascularisation was common with the vascularisation of the medulla which could have made the embolisation dangerous. Conclusion: Although the occurence of a lumbosacral medullar ischemia secondary to an Adamkiewicz arteria lesion is rarely reported in the literature, the preoperative angiography reduces this potential risk. The exact knowledge of the anterior medullar vascularisation allows to better plan the surgical strategy and to adapt the side of operative approach. Furthermore, the angiography enables to perform a selective embolisation of tumors safely

Purpose: To evaluate fellowship trainee and supervisor perceptions on the relative importance of core cognitive and procedural competencies in spine subspecialty fellowship training. Method: A questionnaire was designed through synthesis and amalgamation of two previous surveys designed by other authors. This questionnaire was reviewed for content by spine surgery experts (Canadian Spine Society Education Committee). The questionnaire was administered (online and paper) to fellow trainees and supervisors across Canada and data was collected over a 3-month period. It consisted of 40 MCQ items grouped into 13 broad cognitive skills categories, as well as 29 technical/procedural items. Data was analyzed using qualitative and descriptive statistics (e.g. average mean scores, standard deviations, t-tests). Results: The response rate was 91%, with 15 of 17 fellow trainees and 47 of 51 supervisors completing the survey. Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of 29 spine surgery technical skill items. Specifically, additional training was believed to be required for intradural procedures (e.g. syringomyelia, intradural neoplasms) and other less common, technically demanding, procedures (e.g. transoral odontoidectomy, anterior thoracic discectomy). Significant differences (p< 0.05) existed in perceptions of importance for specific cognitive and technical skills based on previous residency training (orthopaedic or neurosurgical). No such differences were found when comparing responses of the fellow trainees and their supervisors. Conclusion: This study demonstrates that fellowship trainees and supervisors have similar perceptions on the relative importance of specific core cognitive and procedural competencies required in achieving successful spine fellowship training. Furthermore, background specialty training (orthopaedic or neurosurgical) influences the perceptions of both fellow trainees and supervisors regarding the importance of specific cognitive and technical skills deemed necessary for successful training

Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. We performed two separate investigations: [1] 15 participants (9 expert surgeons, 3 fellows and 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach; [2] three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching. A total of 42 pedicles were tested. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences between the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. To our knowledge, these axial force data are the first available for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching, throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery

Background. Depression, anxiety, catastrophising, and fear-avoidance beliefs are some of the so-called “yellow flags” that predict a poor outcome in back patients. Many surgeons have difficulty assessing yellow flags, perhaps due to the complexity of existing instruments and time constraints during consultations. We developed a brief tool to allow the systematic evaluation of core flags. Methods. Data from 4 questionnaires (ZUNG depression (N=399); Hospital Anxiety and Depression Scale (Anxiety-subscale) (N=308); Pain Catastrophising (N=766); Fear Avoidance Beliefs (N=736)) were analysed to identify the respective single item that best represented the full scale score. The 4 items formed the “Core Yellow Flags Index” (CYFI). 1'768 patients completed CYFI and a Core Outcome Measures Index (COMI) preoperatively, and COMI 3 and 12mo later (FU). Results. The individual flag items correlated with their corresponding full-length questionnaires: 0.71 (depression), 0.81 (catastrophising), 0.77 (anxiety), 0.83 (fear avoidance beliefs). Cronbach's α for the 4 items was 0.79. Structural equation modelling revealed that CYFI explained a unique proportion of the variance in COMI at 3 months' FU (β=0.23, p< 0.001) and also at 12 months FU (β=0.20, p< 0.001). Conclusion. The 4-item CYFI proved to be a simple, practicable tool for routinely assessing key psychological attributes in spine surgery patients; it made a relevant contribution in predicting postoperative outcome. CYFI's items were similar to those in the “STarTBack screening-tool”, used in primary care to predict back pain chronicity, further substantiating its validity. Its wider use may help improve the accuracy of predictive models derived using spine registry data. No conflicts of interest. No funding obtained

Aims. The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent. Methods. This was a comparative study using prospectively collected data from the Norwegian Registry for Spine Surgery. A total of 4,750 consecutive patients who underwent surgery for degenerative cervical radiculopathy and were followed for 12 months were included. Case-mix adjustment between those managed in public and private hospitals was performed using propensity score matching. The primary outcome measure was the change in the Neck Disability Index (NDI) between baseline and 12 months postoperatively. A mean difference in improvement of the NDI score between public and private hospitals of ≤ 15 points was considered equivalent. Secondary outcome measures were a numerical rating scale for neck and arm pain and the EuroQol five-dimension three-level health questionnaire. The duration of surgery, length of hospital stay, and complications were also recorded. Results. The mean improvement from baseline to 12 months postoperatively of patients who underwent surgery in public and private hospitals was equivalent, both in the unmatched cohort (mean NDI difference between groups 3.9 points (95% confidence interval (CI) 2.2 to 5.6); p < 0.001) and in the matched cohort (4.0 points (95% CI 2.3 to 5.7); p < 0.001). Secondary outcomes showed similar results. The duration of surgery and length of hospital stay were significantly longer in public hospitals. Those treated in private hospitals reported significantly fewer complications in the unmatched cohort, but not in the matched cohort. Conclusion. The clinical effectiveness of surgery for degenerative cervical radiculopathy performed in public and private hospitals was equivalent 12 months after surgery. Cite this article: Bone Joint J 2023;105-B(1):64–71

Summary Statement. Incorrect pedicle screw placement can lead to neurological complications. Practice outside the operating room on realistic bone models, with force feedback, could improve safety. Pedicle forces in cadaveric specimens are reported, to support development of a training tool for residents. Introduction. Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications and poor mechanical fixation. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide orthopaedic residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. Methods. We performed two separate investigations. In the first study, 15 participants (9 expert surgeons, 3 fellows, 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach. In the second study, three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching, in randomised order. A total of 42 pedicles were tested. Results. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), which was significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences among the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. Discussion. To our knowledge, axial force data have not previously been reported for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery. The opportunity to learn and practice outside of the operating room, including learning from deliberate mistakes, should increase the confidence and comprehension of residents performing the procedure, enhance patient safety, reduce surgical time, and allow faster progression of learning inside the operating room

Introduction: The principles of treatment of deep wound infection around bony implants involves appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals. Methods: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from 4 years to 3 months. Results: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics. Discussion: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care

INTRODUCTION: The principles of treatment of deep wound infection around bony implants involve appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals. METHODS: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from four years to three months. RESULTS: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics. DISCUSSION: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care

The aim of this study was to test the effectiveness of a nurse practitioner-led clinic for managing the pre and postoperative care of patients undergoing lumbar spine surgery, against traditional clinic treatment. Ninety patients were randomised- 46 (Group 1) attended a nurse practitioner run pre-operative class and post-operative follow-up clinic and 44 (Group 2) were seen by the surgeon before and after the operation. All patients completed the Low Back Outcome Score, MSPQ and Zung score, pre-operatively and at six months post-op. There were 46 male and 44 female patients, and mean age was 45.4 years (range 20–77). The two groups were demographically similar (p = 0.418). The mean pre-op outcome score was 23.49 in group 1 and 17.41 in group 2 (p = 0.038) and the mean post-op scores were 44.67 and 35.38 for group 1 and 2 respectively (p = 0.021). Intra-group comparison showed an improvement in post-op outcome score for all patients (p = 0.001), but those in group 1 were significantly more satisfied (p = 0.008). Four theatre slots were lost in group 2 but none in group 1. A nurse practitioner-led pre-op counselling and post-op follow-up is more effective than the traditional clinic attendance for patients undergoing lumbar spine surgery and prevented waste of theatre time