Abstract

Introduction

The British Spinal Registry (BSR) is a web-based database commissioned by the British Association of Spine Surgeons (BASS) in the UK. It allows auditing of spinal surgery outcomes, patient's safety and overall experience. The clinical data include patient's demographics which is entered into the Registry by medical staff, as well as patient-reported outcome measures (PROM) that is submitted to the Registry by the patient themselves at different time periods post-operatively. It has the ability to register Device and Implants as well as co-ordinate multicentre research. This study is to identify both the staff and patient compliance regarding to data submissions to the BSR at St. George's Hospital NHS Trust.

Introduction

Missile injuries are very serious injuries particularly in the cervical region. They are classified into high and low missile injuries when it involves the cervical spine. In modern guerrilla warfare, one must be aware of ballistic pathology with bullets as well as from explosives. In particular, improvised explosive devices commonly known as IED's play a new and important pathophysiology whether they are suicided vests or roadside bombs. They usually produce severe or lethal injuries and serious neurovascular deficit is frequent. We present the details of 40 patients with local experience on how to handle serious penetrating cervical missile injuries.

Introduction

Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery.

Introduction

Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone.

Introduction

Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges.

Adolescent Idiopathic Scoliosis (AIS) patients were subjected to four weeks of Physiotherapy Scoliosis Specific Exercise (PSSE). 124 (Exclusion = 3) Patients were enrolled and assigned to either complete their treatment in one 4-week bout (4WC) (63 patients, M_age = 14.52), or to complete their treatment in two separate fortnightly bouts (2X2WC) (63 patients, M_age = 14.26). Clinical exam, surface topography and Scoliometer readings were compared. The SRS-30 questionnaire before and after treatment was conducted at 6, 12, 18 and 24 months.

Group 1 (4WC) showed significant improvements from baseline (Pre-3.73 – Post 3.9; p=0.026) after the course of treatment, and showed significant improvements at 12 months follow up in Mental Health (p=0.006), Aggregate score (p= 0.005) and Satisfaction score (p=0.011). Satisfaction score remained statistically significant at 18 months follow up (p=0.016). Group 2 (2X2WC) did not record a significant improvement from baseline (p=0.058); however, showed significant improvements in self-image (p=0.013). There was no statically significant difference in SRS scores with respect to follow up time.

We conclude that Physiotherapy Scoliosis Specific Exercise (PSSE) is a successful non-invasive therapy for AIS. The modified Schroth technique (ScolioGold) shows significant improvement in SRS30 scores with the 4-week intensive course that are sustained at a 2 year follow up.

Background

Carbon fibre (CF) instrumentation is known to be radiolucent and has a tensile strength similar to metal. A specific use could be primary or oligometastatic cancer where regular surveillance imaging and Stereotactic Radiotherapy are required.

CT images are inherently more prone to artefacts which affect Hounsfield unit (HU) measurements. Titanium (Ti) screws scatter more artefacts. Until now it has been difficult to quantify how advantageous the radiolucency of carbon fibre pedicle screws compared to titanium or metallic screws actually is.

INTRODUCTION

The correct placement of pedicle screws is a major part of spine fusion and it requires experienced trained spinal surgeons. In the era of European Working Time Directive (EWTD), surgical trainees have less opportunity to acquire skills. Josh Kauffman (Author of The First 20 Hours) examined the K. Anders-Ericsson study that 10,000 hours is required to be an expert. He suggests you can be good at anything in 20 hours following 5 methods. This study was done to show the use of accelerated learning in trainees to achieve competency and confidence on the insertion of pedicle screws.

A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH.

Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines.

Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline.

The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO.

Introduction

Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies.

Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies.

We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015.

Introduction

Sling immobilization of the upper limb may affect balance. Computerized dynamic posturography (CDP) provides a validated, objective assessment of balance control and postural stability under dynamic test conditions. We tested the balance of individuals with a shoulder stabilization sling (SSS) using an Equitest Machine to objectively assess imbalance wearing a sling.

Aims

Hip fractures pose a significant burden on the healthcare system. Hyperglycaemia and a state of Type 2 diabetes exists post operatively. Being normoglycaemic has well documented benefits. Pre operative carbohydrate loading has been shown to have two good effects. It decrease hyperglycaemia post operatively and allows the patient to undergo less strict fasting protocols. Insulin resistance to date has not been examined in these patients and this was determined using a validated formula (HOMA/IR).

Fracture neck of femur (NOF) is a significant morbidity in the elderly patient and a significant burden on the healthcare system. Surgery induces a stress response resulting in hyperglycaemia, insulin resistance, and glucose intolerance (Diabetic triad). Furthermore, fasting pre operatively establishes a catabolic state. This diabetic state can last up to 3 weeks following surgery and therefore could be associated with the morbidity of diabetes.

We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis.

Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years.

According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage.

A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient.

Introduction: Surgery may cause a metabolic response leading to a diabetic state characterised by hyperglycaemia, insulin resistance and glucose intolerance. Metabolic stress may be worsened by the practice of Nulla Per Os (NPO).

Hip fracture patients are often subjected to fasting for extended periods. We hypothesise that a pre operative high carbohydrate drink permitted prior to surgery would mitigate the post operative diabetic state.

Methods: Ethical and Anaesthetic approval were obtained. 40 patients with hip fractures were enrolled over 4 months at Mayo General Hospital and were randomized to two groups. 20 were enrolled into Group A: control traditional NPO and Group B: Carbohydrate group. Data collection: Glucose and insulin serum levels were recorded regularly at: preadmission, post op and post op days 1 & 5; and weeks 2,3 & 6. Drink protocol: 800mls before midnight and 400mls on the morning of surgery. Exclusion criteria included diabetics and pregnancy. Hospital length of stay (HLOS), morbidity and readmissions were noted.

Result: Average age Group A: X Group B:Y. Hyperglycaemia post operatively noted in 70% of Group A vs 30% in Group B. Hyperinsulinaemia postoperatively noted in 75% of Group A vs 28% Group B. Group A and B had similar HLOS and post operative morbidity. However, we noted a higher readmission rate 45% in Group A.

Conclusion: Preoperative Carbohydrate loading significantly decreases post operative hyperglycemia and hyper insulinamia. This may show that converting a patient from fasted to a fed state prior to the insult of surgery prevents the patient entering a diabetic state and avoiding morbidity associated with same.

Introduction: Definitions of surgical site infections are based on those of CDC, published in 1992. Infections that occur within 30 days of surgery are classified as:

Superficial – involves only the skin or subcutaneous tissue.

Between 2006 and 2008 the infection rates of the National Spinal Surgery Unit have been closely monitored as part of a multidisciplinary team approach led in large part by the Infection Control Team. A surveillance protocol was developed. They prospectively monitored every spinal surgery patient as part of a infection control data base. Biographical and medical history data were collated including diabetic status, prophylactic antibiotic use and surgical procedure. Information was collated and feedback on changes was examined by audit which was conducted regularly.

Methods: As part of the routine audit of the NSSU department a deep infection rate of 3.5% was noted in 2006. The infection control team set up a specific unit to co ordinate surveillance of NSSU. We describe simple and evidence based protocols for prophylactic antibiotic use in conjunction with the Pharmacy, Infection Control and Microbiology department was organised in running with international standards. Furthermore, surgical, nursing and paramedical staff, involved in the NSSU, were swabbed routinely. New rigid guidelines were introduced in theatre for draping patients including the addition of topical alcohol use and 8 minute minimum bethidine drying time.

Results: From 2006, deep infection rate was 3.5%. This was followed by a 2.49% in 2007 and 1.79% in 2008. Of note the deep infection rate in 2004 was 5.5% (2 years prior to implementation of Infection Control protocols).

Conclusions: The National Spinal Surgery Unit was able to decrease the deep infection rate by 51% over 3 years by the implementation of careful prospective surveillance by a multidisciplinary team involving an Infection Control team which monitored the NSSU prospectively as well as co-ordinating changes in the protocol of antibiotic use as well peri-operative sterile techniques. We describe simple protocols which can be easily used in other institutions to aid in the mitigation of deep spinal surgical infection.

Introduction: K wiring is a popular technique to help maintain anatomic reduction of distal radial fractures. It has the advantage of being a semi-closed procedure, which is simple to perform. Complications related to K wires include infection, migration and damage to tendons and nerves.

We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.

Methods: We prospectively recruited 60 consecutive patients with displaced distal radius fractures requiring K wiring to our study. They were randomized to Buried versus Exposed K wire groups.

Patient details were collected and follow up was performed at 2 and 6 weeks post op.

Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.

Results: 60 consecutive patients were recruited to the study and randomized to buried or exposed k wires. There were 30 patients in each group.

No damage to EPL tendon was recorded in either group at 6/52 follow up.

There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.

Conclusion: There appears to be slight increased risk of superficial pin site infection in the exposed k wire group at 2/52 but this is not seen at 6/52 follow up. Buried k wires require a second procedure to remove the wires and this runs the risk of superficial radial nerve damage.

Introduction: Strict maintenance of normoglycaemia with intensive insulin therapy in the critically ill surgical patients has helped to reduce morbidity and mortality by almost 50%. The notion that insulin may act independently of glucose as an anti inflammatory agent is of interest. Orthopaedist manipulate the inflammatory cascade through the practice of Damage Control Surgery. By delaying surgery they prevent a second hit in the Systemic Inflammatory Response Syndrome (SIRS) and attenuate excessive inflammation which may lead to Multiorgan Failure (MOF). An insulin infusion is a novel method of modulating the inflammatory cascade through the strict control of hyperglycaemia.

The role of neutrophils and endothelium are an integral part of the inflammatory cascade. Our aim was to investigate whether insulin had an independent effect on endothelial cell activation.

Aim: We hypothesise that insulin, independent of glucose, has a cytoprotective effect on the endothelium as an anti inflammatory agent.

Methods: We subjected human umbilical vein endothelial cells (HUVEC) to normoxia, hypoxia and hypoxia reoxygenation to simulate trauma. These 3 groups were incubated with insulin at 0uU/ml, 10uU/ml, 50uU/ml and 100uU/ml for 24h and 48h normoxia and hypoxia. For the hypoxia reoxygenation study HUVEC were exposed to 24h of hypoxia and then 24h of reoxygenation. Proliferation of endothelial cells was measured using an MTT study.

Results: Our experiment shows that hypoxia reduces HUVEC proliferation. Results show that treatment with 50uU/ml insulin for 24 hours attenuates the effect of hypoxia. This suggests that insulin at post prandial, physiological levels, in non diabetics has a cytoprotective effect on endothelial cells. This was significant in hypoxic conditions in a dose dependent manner.

Conclusions: Hypoxia simulates injury and when injury occurs it activates an inflammatory response which could lead to SIRS. It has not previously been investigated how insulin acts as an anti inflammatory mediator in the control of hyperglycaemia. We can conclude that insulin may act to protect the endothelium, independent of glucose, under hypoxia and hypoxia reoxygenation conditions.

Introduction: K wiring is a popular technique to help maintain anatomic reduction of distal radial fractures. It has the advantage of being a semi-closed procedure, which is simple to perform. Complications related to K wires include infection, migration and damage to tendons and nerves.

We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.

Methods: We prospectively recruited 60 consecutive patients with displaced distal radius fractures requiring K wiring to our study. They were randomized to Buried versus Exposed K wire groups.

Patient details were collected and follow up was performed at 2 and 6 weeks post op.

Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.

Results: 60 consecutive patients were recruited to the study and randomized to buried or exposed k wires. There were 30 patients in each group.

No damage to EPL tendon was recorded in either group at 6/52 follow up.

There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.

Conclusion: There appears to be slight increased risk of superficial pin site infection in the exposed k wire group at 2/52 but this is not seen at 6/52 follow up. Buried k wires require a second procedure to remove the wires and this runs the risk of superficial radial nerve damage.

Thus it would appear that leaving k wires exposed is the safer and more convenient method of K wiring the displaced distal radius fracture.

Introduction: Fasting overnight NPO (Nulla per os) has been routine before surgery for the past century. The practice was previously designed to reduce the risk of pulmonary aspiration on induction. However this practice has been challenged over the recent years and is changing anaesthetic practices are now more liberal. There are many new concepts aimed at improving patient outcome by regulating metabolic, endocrine, inflammatory and immune responses. This combined with better patient satisfaction and lower anxiety has led to research in this area.

Overnight fasting can induce post operative insulin resistance. Insulin resistance is related to infectious morbidity and increased hospital length of stay (HLOS). Previously this concept was only important in diabetic patients. Surgery places the body under metabolic stress and even a short period of fasting will change the metabolic state of the patient. Indeed physical trauma can cause a triad known as the “diabetes of injury”: insulin resistance, hyperglycaemia and glucose intolerance. Preparation for surgery by maintaining a fasted state and catabolic metabolism may have deleterious consequences for the patient.

Previous studies on elective patients has shown that pre operative carbohydrate loading can reduce insulin resistance and mitigate the inflammatory response by immunomodulation. It has not previously been shown to have an effect in the hip fracture population. This particular group of patients are often elderly and require medical and anaesthetic work up. This delay can mean that the patient is kept fasting for prolonged periods and often overnight.

Methods: With full ethical approval at Connolly Hospital we prospectively randomised all femoral and hip fractures for surgery. We excluded diabetics and pregnant women from the study. A high carbohydrate drink called Nutritia Pre Op was selected. Random serum glucose was taken on admission. Patients were randomised and selected for the trial by hidden ballot. Anaesthetic approval was sought for each case. We compared our standard treatment for hip and femoral fractures of strict NPO prior to surgery versus giving patients the Pre Op drink. Each carton was 200ml and up to 4 were given the night before surgery. In the morning the patients were given another 2 drinks. There was a strict minimum 2 hour NPO period before leaving the ward. Glucose levels were then taken at 1 and 12 hours post operatively to assess whether hyperglycaemia was present. As per laboratory values a normoglycaemia was considered as 4–6mmol/l. Gender, age, type of operation, HLOS, complications and re-admissions were noted.

Results: In total 17 patients were enrolled in the study. Group A had 9 patients and were kept NPO as the control group. Group B had 8 patients enlisted in the Pre Op Drink group. In group A, 6 of 9 (67%) patients had a post operative hyperglycaemia. Average age in group A was 79.6 years with an average HLOS of 15.8 days. 4 patients between them required 8 readmissions over a 3 month post operative period. Group B showed 2 out of 8 (25%) patients had a hyperglycaemia. They had an average age of 69 years with an average HLOS of 11.75 days. 4 patients required 4 readmissions.

Conclusions: Pre Op high carbohydrate drinks significantly decrease post operative hyperglycaemia as per the laboratory ranges. This in turn supports that it decrease insulin resistance by preparing the body for surgery in a fed state. In the same way that one would not prepare for a marathon by fasting 24 hours before hand so the body recognizes that the surgical stress is not best dealt with when in a fasted state. The control group had twice as many readmissions and a longer HLOS. Previous studies show that there is decreased anxiety, thirst and hunger both pre and post operatively. We have shown that this is a safe drink to give and that post operative hyperglycaemia was better controlled.