Purpose

The treatment of C2 fractures with collar, halo or surgery can all be justified depending on the patient. In our unit, primary treatment is with a halo: in a previous study presented at BASS we found an 85% fusion rate. In a follow on study, we wished to assess the outcome in those patients who underwent surgical treatment.

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy.

Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD).

A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant.

Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes.

Royal Liverpool University Hospital, Liverpool, UK

To retrospectively review outcomes in patients who underwent vertebroplasty in Liverpool in response to recent level 1 publications claiming vertebroplasty to be no better than sham procedure assessed using 2 criteria. We reviewed cases between 2006 and 2009 looking at 5 criteria for procedure.

Visual Analogue Score (VAS)

Oswestry disability index scores (ODI)

96 patients identified. 10 patients excluded (inadequate data recorded) (n=86). Operated levels n=134 (thoracic n=61, lumbar n=71, sacral n=2).

Presenting symptoms included back pain (86/86) and point tenderness was present in 90% (77/86). Average length of symptoms was 11.50 months with 28% reporting greater than 12 months. 72% recalled definite onset of symptoms with 90% being associated with a low velocity injury. Radiological findings showed an average of 54% height collapse and 91% showing high signal on STIR MRI sequences. Number of levels operated – 3 or more (n=9 VAS 5.3 ODI 10.6); 1 to 2 levels (n= 77 VAS 3.7 ODI 13.9)

Average improvement in VAS score was 3.8.and ODI 13.6

47% (40/86) of patients met all 5 current criteria recommended for operation (VAS 3.7, ODI 14). 53% (46/86) of patients met 2-5 criteria (VAS 3.8, ODI 13.4).

There was improvement in pain scores in 91% of patients with an average pre-op VAS 7.8 and post-op VAS 4.0. There was no significant difference in patients meeting all 5 criteria compared to those meeting 2-5 criteria.

To review the accuracy of our systematic process in preventing wrong level lumbar microdiscectomy.

X-ray is used to identify the correct level for the skin incision to be made, x-ray is again used if the surgeon is in doubt prior performing the flavotomy. Following a lumbar microdiscectomy a Watson Chane is inserted into the empty disc space and an intra-operative x-ray is taken to confirm the level the discectomy has occurred. Observers A and B independently reviewed intra-operative x-ray in patients undergoing lumbar microdiscectomies and correlated the accuracy of the x-ray in determining correct level surgery against the pre-operative MRI scan and the preposed level of surgery.

123 patients, 66 males and 57 females underwent 127 lumbar microdiscectomy procedures between 2007 and 2009. The levels where surgery occurred are;- L2/3 -1 patient, L3/4–8 patients, L4/5–53 patients and L5/S1-65 patients.

Kappa coefficient was used to determine inter-observer and Pearson Correlation coefficient was used to determine the X-ray and MRI relationship

Percentage of patients who required a pre-flavotomy x-ray level check are:- L2/3–100%, L3/4-63%, L4/5–45%, and L5/S1–40%. Pearson's correlation in confirming the level lumbar microdiscectomy was performed using final x-ray and the pre-operative MRI scan was 1. Kappa coefficient between observer A and B was 1.

This process of using intra-operative x-ray in determining the exact level where lumbar microdiscectomy was performed is 100% accurate. This is our standard process in preventing wrong level surgery for lumbar microdiscectomy.

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy.

Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD).

A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant.

Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes.

Review the complications reporting in 4 prominent spinal journals over the last decade.

Computerised search of the Medline database and hand search was undertaken to evaluate the complication reporting in 4 spinal journals (Spine, European Spine Journal, Journal of Neurosurgery Spine and Journal of Bone and joint surgery) from 2000 to 2009. The articles were divided based on the level of NICE evidence classification A to D.

A total of 88 articles reported spinal complications. Of these 5.9% was level B, 8.8% was level C and 85.3% was level D. There were no RCT's reported relating to complications (Level A) and majority of complications were case reports or expert opinions (level D). For the proportion of level D the rank order of the journals was; Spine (4.8%), European spine journal (3.8%), Journal of neurosurgery spine (5.1%) and Journal of bone and joint surgery was (1.8%). There was no increase in the rate of reporting over the decade. A detailed discussion of the reporting will be presented.

Papers focusing primarily on complications and its management are still not the focus in most surgical journals. This review over the last 10 years confirms that only rare and uncommon complications are reported in the form of case reports. Meta analysis or case series of complication is rarely reported. More focus must be emphasised on reporting mortality and morbidity for education.

Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 1986¹ we aimed to compare our figures with published literature.

Methods: A retrospective case note review (1994–2004). One investigator reviewed the case notes and corroborated these with a spinal database, theatre database and microbiology results system.

Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females.

28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA).

Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10).

8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%).

Pin site infection was diagnosed using an accepted definition². This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team² from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter.

The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient.

Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench³. Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing.

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery.

Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization.

Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively.

Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.

Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery.

Ethics approval: None Audit

Interest Statement: None

Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 1986¹ we aimed to compare our figures with published literature.

Methods: A retrospective case note review (1994–2004). One investigator reviewed the casenotes and corroborated these with a spinal database, theatre database and microbiology results system.

Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females.

28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA).

Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10).

8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team² from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter.

The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient.

Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench³.

Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing.

Objective: This was to analyse RLBUHT orthopaedic spinal service’s provision of spinal care and to determine the impact on the need for surgery.

Methods: This was a three-year retrospective cohort study of orthopaedic patients with spinal related problems from January 2003 to January 2006. The sample included all patients referred to the service by general practitioners in Liverpool. Patients were examined by orthopaedic musculoskeletal physiotherapists lead by senior specialist therapists. The latter had autonomy to access imaging investigations and blood tests. Patients were referred to the consultant surgeons for surgical consideration when appropriate or to the physiotherapy department for non-surgical management. Outcome measures used included the Stockport Scale, the Roland and Morris Disability Questionnaire, the Neck Disability Index, the Euroquol Questionnaire and the Visual Analogue Scale.

Results: 17,214 patients were referred to the service from January 2003 to January 2006. 9,896 patients attended, 2,600 failed to attend and 4,718 cancelled their appointments. The number of referrals increased from 4,499 in 2003 to 5,695 in 2004, and 7,020 in 2005. Patients going on for surgery remained 200 to 220 cases per annum. The waiting times to surgery decreased from 3 to 6 months, to within 3 months. An audit of 300 patients discharged from the physiotherapy department using the Stockport Scale from January 2005 to January 2006 revealed that problems were solved / goals achieved in 40.3% of patients, with significant improvement in 42.7%, some improvement in 8.3% and no improvement or no data in 8.7%.

Conclusion: Over the three-year period there has been a significant increase in the number of patients managed by this service. This has not resulted in an increase in patient waiting-time. Surgical intervention per head of population has not altered and has been sooner. Our experience demonstrates an effective model of care for large urban populations.

Background: To assess the accuracy of pedicle instrumentation placement using an image guidance system ( Medi Vision) in a pig cadaveric model.

Methods: A 4mm diameter (10cm long) screw was inserted transversely into the spinous process of a pig cadaver percutaneously using fluoroscopic guidance. The dynamic reference base (DRB) of the image guidance system was then attached to the screw. Using the navigation system both pedicles at each level were identified and 3.2mm guide wires inserted percutaneously. This process was performed for each level from D7 to L4. Actual wire placement was recorded using standard anteroposterior and lateral fluoroscopic images. Virtual trajectories generated by the image guidance system were recorded on the guidance system database. Accuracy of wire placement was then evaluated in an automated way by linear correlation between corresponding images.

Results: 20 pedicles were instrumented at 10 levels from D7 to L4. Mean estimate of accuracy for dorsal levels AP and lateral (mm). Mean = 1.452mm, standard deviation 1.57mm. Mean for lumber levels= 1.047mm, standard deviation 1.187mm

Conclusion: Lumbar pedicle instrumentation showed more accuracy when compared to dorsal pedicle instrumentation. The error of navigation that was accommodated by the image guidance system was 2mm.

There was correlation between fluoroscopic copies and virtual trajectories.

This image guidance system may not only aid in the placement of pedicle instrumentation but also assist the senior surgeon in trainee supervision.

Study Design: Prospective case series of patients with tumour involvement of the spinal column consecutively admitted to a spinal unit for consideration of surgical treatment.

Objectives: To assess the impact of surgery on the quality of the life of patients suffering from metastatic or primary tumours of spine. Pre-operative assessment included the SF-36 and Oswestry Disability Index (ODI). Other scores (eg Tokuhashi) were prospectively calculated but were not used to determine suitability for surgery.

Subjects: A total of 38 patients were assessed. Of these 25 were considered suitable for surgery. Of these 25 patients, 3 died within 3 months and one had incomplete follow-up. The remaining 21 patients underwent further assessment at 3 and 6 months. A total of 8 patients are now dead in this group. Of 13 non-operated patients, one was unable to do an initial self-assessment. Of the other 12 patients, 4 were dead before second assessment. The remaining 8 patients provided us with another self-assessment. A total of 5 patients are now dead in this group.

Outcome measures: The SF-36 and ODI were repeated at 3 and 6 months. Those patients who were not considered suitable for surgery were also reassessed at 3 and 6 months, although the groups were not strictly comparable.

Results: At the time of presentation, most of the patients were severely or completely disabled. As expected, their Physical and Mental Health Component Scores of SF-36 were lower than reference values for patients with chronic ill health. The mean Bodily Pain scores were 12.84 in the operated group and 31.19 in the group managed conservatively. The initial ODI were 57 in the operated group and 59 in the conservative group. Of 25 patients who underwent surgery, 15 had posterior stabilisation and 7 had anterior reconstruction. 1 patient had a combined approach. 1 patient was stabilized with a halo vest and another had his procedures abandoned. Pre-operative and postoperative scores were compared using a paired two tail students t test. Mean Oswestry scores showed significant improvement at the 3rd month (from 57 to 48, p=0.02) and this was maintained at the 6th month. Among the various components of the SF-36 score, the most significant improvement was seen in Bodily Pain (from 12.8 to 46.8, p=0.00006). This was also maintained at 6 months. The mean Mental component scores improved significantly at the 3rd month (from 39.5 to 48, p=0.0009) and remained improved at the 6th month (44). In the non-operated group, the situation deteriorated in all respects. Mean Bodily pain scores (from 31.16 to 14.63, p=0.001), Physical component scores (from 28.48 to 19.72, p= 0.007) & Mental component scores (from 46.41 to 38.83, p= 0.05) were all significantly worse than at the initial assessment. The mean Oswestry disability score, also showed increasing disability (from 57 to 73.5) but did not reach statistical significance (p=0.16).

Conclusions: Surgery in these patients leads to a less painful and less disabled life. The quality of life improved in terms of mental health and physical health.