To determine the factors that influences the clinical outcomes in surgical correction of thoracic AIS. There are conflicting data regarding the effects of back shape and radiologic parameters on the self-reported outcomes of surgery in AIS. Prospective, cohort study; mean follow-up 29 months (range 9-88). 30 patients (5 males);. Rib hump 17 ° corrected to 7 °. Thoracic Cobb 66 ° corrected to 25 ° (63%). Lumbar Cobb 42 ° corrected to 17°. Thoracic apical vertebral translation (AVT) 48mm corrected to 18mm. Lumbar AVT 34mm corrected to 19mm. Thoracic kyphosis 29° preoperatively 23° postoperatively. Lumbo-sacral lordosis 57° preoperatively 49° postoperatively. Modified SRS Outcomes Instrument (MSRSI) filled out pre-operatively and at final follow up. Primary= rib hump, radiological (frontal Cobb correction, lumbar & thoracic AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI) domain scores. The magnitude of the rib hump had a significant association with pain:. Rib hump vs. MSRSI pain r= -0.55 p<0.000. Similar correlations existed between rib hump and self-image (r=-0.64, p<0.0000), thoracic Cobb angle with pain (r=-0.48 p<0.0001) and self-image (r= -0.57, P<0.0000). The postoperative thoracic Cobb angle, and percentage thoracic Cobb correction had significant correlations with self-image (r=-0.55 p=0.003 & r=0.54 p0.004 respectively). The size of the rib hump has a significant impact on pain & self-image. These domains are also significantly influenced by the residual thoracic Cobb angle and overall scoliosis correction

We present a large single surgeon case series evaluation of a new growth guidance technique for the treatment of progressive early onset scoliosis (EOS). A traditional Luque trolley construct uses wires to hold growth guidance rods together. We describe a new technique that uses domino end to side connectors in place of the wires with the aim of providing a stronger construct to better limit curve progression, while allowing longitudinal growth.

We did a thorough retrospective review of patient records and radiological imaging. Sequential measurements of Cobb angle and length of rods were recorded, as well as any further surgical procedures and associated complications. This enabled us to quantify the ability of a technique to limit curve progression and simultaneously allow growth of the construct. In total, 28 patients with EOS (20 idiopathic, four syndromic, and four neuromuscular) have been treated with this technique, 25 of whom have a minimum follow-up of 2 years and 13 have a minimum follow-up of 5 years.

The average correction of the preoperative Cobb angle was 48.9%. At the 2-year follow up, the average loss of this initial correction was 15 degrees, rising to only 20 degrees at a minimum of 5 years (including four patients with a follow-up of 8 years or more). The growth of the constructs was limited. The average growth at 2 years was 3.7 mm, rising to 19 mm at the 5-year follow-up.

Patients who underwent surgery with this technique before the age of 8 years seemed to do better. This group had a revision rate of only 18% at an average time of 7 years after the index procedure, and the average growth was 22 mm. However, the group that had index surgery after the age of 8 years had a 64% revision rate at an average of 3.2 years after surgery and an average growth of only 11.6 mm. Overall, in the cases series, there were four hardware failures (14%) and one deep infection (3.5%), and only ten patients (36%) had one extra surgery after the index procedure. Only two of the 13 patients who are at a follow-up of 5 years or more have had revision.

This modified Luque trolley technique has a good capacity for initial curve correction and for limiting further curve progression, with limited longitudinal growth before 2 years and improved growth thereafter. This technique might not be so useful after the age of 8 years because of poor growth and a higher early revision rate. We have also demonstrated a low cost technique with a low hardware failure rate that saves many future surgeries for the patient compared with other techniques used in the treatment of EOS.

Background

The association between lumbar intervertebral disc degeneration (LDD) and low back pain (LBP) is modest. We have recently shown that genetic propensity to pain is an effect modifier of the LDD-LBP relationship when LDD is defined as a summary score of LDD (LSUM), suggesting the association may be driven by individuals with the greatest genetic predisposition to pain. This study examined the association between individual spine magnetic resonance imaging (MRI)-determined LDD features and LBP in subgroups defined by genetic predisposition to pain.

Background and Aim of Study

Despite several hundred RCTs of exercise for persistent non-specific low back pain (NSLBP), the treatment targets of exercise are unclear. In a systematic review we observed 30 direct and indirect treatment targets of exercise described across 23 RCTs for persistent NSLBP. Since not all treatment targets and outcomes can be assessed in all RCTs, it is therefore important to prioritise these treatment targets through consensus from key stakeholders. These consensus workshops aimed to agree treatment targets for the use of exercise interventions in randomised controlled trials (RCTs) in persistent NSLBP using nominal group workshop (NGW) methodology.

Introduction. Degenerative cervical myelopathy (DCM) is associated with progressive neurological deterioration. Surgical decompression can halt but not reverse this progression. The Modified Japanese Orthopaedic Assessment (MJOA) tool is recommended by international guidelines to grade disease severity into mild, moderate and severe, where moderate and severe are both recommended to undergo surgical intervention. During Covid-19 Nottingham University Hospitals (NUH) NHS Trust, identified DCM patients as high risk for sustaining permanent neurological damage due to surgical delay. The Advanced Spinal Practitioner (ASP) team implemented a surveillance project to evaluate those at risk. Methods. A spreadsheet was compiled of all DCM patients known to the service. Patients were telephoned (Oct-Nov 2021) by an ASP. MJOA score was recorded and those describing progressive deterioration were reviewed by the ASP team on a spinal same day emergency assessment unit. Incident forms were completed for clinical deterioration and recorded as severe harm. Acute, progressive neurological deterioration was fast tracked for emergency surgical decompression. Results. 45 patients were telephoned, 18 (40%) had deteriorated. Of the 18, 9 underwent urgent surgical decompression, 6 still await surgery and 3 continue to be monitored. Those who had deteriorated were sent a formal apology and duty of candour letter. Conclusion. It appears that patients with a diagnosis of DCM deteriorate over time. Delays to timely surgical intervention can have a deleterious effect on patient's neurological function. Baseline assessment should be clearly documented and scoring system such as MJOA considered for effective monitoring. Safety netting for deterioration should be standard practice, and a clear pathway for emergency presentation identified. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Aims. The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS). Methods. We used multi-shot, high-resolution, diffusion tensor imaging (ms-DTI) in patients with cervical spondylotic myelopathy (CSM) to investigate the change in diffusion metrics and clinical outcomes up to five years after anterior cervical interbody discectomy and fusion (ACDF). High signal intensity was identified on T2-weighted imaging, along with DTI metrics such as fractional anisotropy (FA). MJOA, NDI, and VAS scores were also collected and compared at each follow-up point. Spearman correlations identified correspondence between FA and clinical outcome scores. Results. Significant differences in mJOA scores and FA values were found between preoperative and postoperative timepoints up to two years after surgery. FA at the level of maximum cord compression (MCL) preoperatively was significantly correlated with the preoperative mJOA score. FA postoperatively was also significantly correlated with the postoperative mJOA score. There was no statistical relationship between NDI and mJOA or VAS. Conclusion. ms-DTI can detect microstructural changes in affected cord segments and reflect functional improvement. Both FA values and mJOA scores showed maximum recovery two years after surgery. The DTI metrics are significantly associated with pre- and postoperative mJOA scores. DTI metrics are a more sensitive, timely, and quantifiable surrogate for evaluating patients with CSM and a potential quantifiable biomarker for spinal cord dysfunction. Cite this article: Bone Joint J 2020;102-B(9):1210–1218

Introduction. Yellow flags are psychosocial indicators which are associated with a greater likelihood of progression to persistent pain and disability and are referred to as obstacles to recovery. It is not known how effective clinicians are in detecting them. Our objective was to determine if clinicians were able to detect them in secondary care. Methods. 111 new referrals in a specialist spine clinic completed the Oswestry Disability Index (ODI) and a range of other validated questionnaires including the yellow flag questionnaire adapted from the psychosocial flags framework. Clinicians blinded to the patient data completed a standardized form to determine which and how many yellow flags they had identified. Results. The average number of yellow flags per patient was 5 (range: 0–9). Clinician sensitivity in detecting yellow flags was poor, identifying only 2 on average. The most common yellow flag reported by patients was fear of movement or injury (88%), and this was also the yellow flag most frequently missed by clinicians, being identified correctly in only 45% of patients. The most commonly misidentified was patient uncertainty, in 28% of patients. Patients who reported more yellow flags were more likely to score higher on their ODI (p<0.01), Modified somatic perception score (p<0.01) and Modified Zung Depression Index (p<0.01). They also had poorer Low Back Outcome Scores (LBOS) (p<0.01). Conclusion. Clinician sensitivity in detecting yellow flags is poor. Improved identification of obstacles to recovery may improve outcomes. Clinicians may improve detection of these obstacles by having a simple set of questions completed by the patient

Aim. To compare spinal outcome measures between patients reviewed for medico-legal compensation claims relating to perceived injury at work to those having sustained serious structural injury in the form of unstable thoraco-lumbar fractures requiring internal fixation. Method. Two consecutive cohorts of 23 patients with healed spinal fractures and 21 patients with a perception of work related soft tissue injury were compared. Patient demographics and a range of outcome measures including Oswestry Disability Index (ODI), Low Back Outcome score (LBOS), Modified Somatic Perception (MSP) and Modified Zung Depression (MZD) indices were measured. Results. 23 patients (8F; 15M) with spinal fractures (group 1) of average age 42 years (range 22-66) were followed up for a mean of 41 months (range 14-89, SD 23.3) post trauma and compared to 21 patients (6 females; 15 males) with self reported back pain (group 2) of average age 47 years (range 37-63), mean time since perceived injury of 42 months (range 12-62, SD 14.5). Both groups were comparable in terms of age and sex (P = 0.254 and 0.752 respectively). The average ODI was 28% (SD 18.5) compared to 52% (SD 17.1) in group 1 and 2 respectively (P value: 0.000087); LBOS 40 Vs 20 (P=0.000189); MSP 4 Vs 10 (0.01069); and MZD 20 Vs 36 (P=0.000296). Conclusion. Despite high energy trauma and significant structural damage to the spine, post-traumatic patients had better spinal outcome scores in all measures (ODI, LBO, MSP, MZD). This thereby defies 8 of the 9 Bradford Hill criteria of causation. The reasons for such differences are primarily psychosocial. Addressing obstacles to recovery may improve outcomes. There is no ‘dose-response’ curve to functional outcomes. In fact, uniquely the disability seems greater in the lower energy injury which is unique in trauma care

Aims

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

Aims

CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

Background. Being involved in litigation is associated with poor outcomes, higher levels of pain, disability, catastrophising, fear-avoidance and other psychological factors. Poor access to treatments can contribute to chronicity of symptoms and poor outcomes, especially in patients involved in litigation with a longer time since the accident. Purpose. To examine the relationship between time since the accident, access to treatments and current psychological variables. Methods. Eleven patients completed the Pain Catastrophising Scale, Tampa Scale for Kinesiophobia, Zung Depression Inventory, Modified Somatic Perceptions Questionnaire as well as details about the accident, working status and recalled access to treatments. The results were analysed qualitatively and quantitavely. Results. The mean time since the accident was 32 months and the mean measures are: ZDI (41.9±9.3), PCS (33.3±9.4), TSK (47.5±9.2), MSPQ (15±8.4). Eight subjects are not currently working and three are working part-time. There was a positive correlation between time since the accident and depression (r=0.679) and MSPQ (r=0.547) but not for other variables. Average sequence of recalled treatments is outlined. Conclusion. Our results indicate that measures of depression and somatic perceptions keep increasing with time whereas catastrophising and kineshiophobia are relatively constant in a small group of litigants with spinal pain. The recalled treatments reflect a focus on invasive treatments with little long-term positive outcome and only one patient receiving the recommended combined physical and psychological programme. I can confirm that this abstract has not previously been published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Source of funding: No funding obtained

Compare the prevalence of psychological distress in claustrophobic patients compared with a non-affected group, together with determination of presenting disability and overall intervention rates. Retrospective case notes review. 33 patients (13 males) all requiring MRI scan under sedation for claustrophobia (Group 1) were compared with an age and sex matched cohort that had MRI without sedation (Group 2). Both groups were drawn from the same chronic back clinic. Average age in both groups was 54 years (range 27-79 years). Both groups had standard conservative therapy, together with psychometric evaluation. Primary: Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ). Secondary: Oswestry Disability Index (ODI), intervention rates (surgery, injections and physiotherapy sessions). Comparison of means -. 22 patients (66.7%) in Group 1 were discharged after their MRI with no intervention compared to 7 patients (21.2%) in Group 2. Claustrophobic patients with back pain showed higher levels of depression than non-claustrophobic patients, with a greater prevalence of psychological distress. Disability however was the same. The majority of claustrophobic patients had no intervention, with a lower rate than their non-claustrophobic peers. Claustrophobia is a proxy for psychological distress and should be considered in the overall evaluation of chronic back patients

To assess how effective are the prognostic scores and the role of delayed presentation in predicting the outcomes in patients with metastatic spine disease. Retrospectively data collected from December 2006 to December 2009. Medical records review included types of tumours, duration of symptoms, duration from referral to definitive treatment, expected survival, functional status before and after treatment. Karnofsky performance score and Modified Tokuhashi were used. Results: 50 patients underwent surgical stabilisation for metastatic spine disease with or with out cord compression. Age ranged from 39 to 87 years (Avg: 64). Patients had four main types of tumours; (Myeloma 30%, Lymphoma 22% Lung CA 16% and Renal 12 %). Inpatients without cord compression, the average time from referral to definitive treatment is 17 days. Over all fictional status improved in 70% of cases following surgical intervention. Patients who presented with cord compression had surgery with in 49 hours. Patients with high prognostic scores did not survive as long as expected. On the contrary, patients with poor prognostic scores survived longer than expected. This discrepancy is significant in patients with lung and renal malignancies. Patients with Myeloma did well as per the prognostic scores. Prognostic scores are not uniformly effective in all types of malignancies. Factors like delayed presentation and general condition were not included in the prognostic factors. Hence, we conclude that we cannot make a decision purely based on the prognostic scores to perform either palliative or definitive surgery

To prospectively determine the relationship between the two most commonly used generic spinal outcome measures, the Oswestry Disability Index (ODI) and the Low Back Outcome Score (LBOS). Outcome measures inform audit and research. Few spine surgical specific outcome measures are in general use. Generic measures are used for a variety of spinal disorders it is not known which is best or exactly how they relate for different conditions. Pre-operatively and two years post surgical results were available in 240 patients. There were 125 males, 115 females. Sub groups numbering 82 discetomy, 78 decompression, 26 revision and 19 fusions were analysed. Average age 55 years (range 23-88). The pre op average ODI was 55% and the LBOS was 29. Correlation was -0.73. The overall post operative score at 2 years was 34% ODI and 37 LBOS, the correlation was better at -0.87. The correlation between the two scores post operatively was very good for Discectomy surgery (-0.916) and fusion surgery (-0.907) but not so close pre operatively with Discectomy (-0.786) and fusion correlation poor at (-0.302). Revision surgery and decompression surgery had similar good correlation post operatively. The correlation of both outcome measures to the Modified Zung depression index was poor. The poor pre operative correlation suggests that thresholds for surgery cannot be compared within registries using different measures. The post operative scores and change in scores correlate better. This is important in comparative studies using different outcomes scores within the same spine registry. No conflict of Interest. Registered database and audit of service standard

Comparison of clinical, radiological & functional outcomes of corrective surgery for right thoracic AIS curves. There is a paucity of data relating functional outcomes to the radiological and surface measurement results of either posterior or anterior surgery for right thoracic AIS. Prospective, cohort study, mean follow up 35 months (range 9-115). 38 patients (6 males); 22 Lenke 2 posterior, 16 Lenke 1 anterior. Primary= rib hump, radiological (frontal Cobb correction, apical vertebral translation AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI). Secondary= estimated blood loss (EBL), operative time, complications. No significant difference at P<0.005 with student t-test unless indicated. Rib Hump: 16° posterior 17 ° anterior, corrected to 8 ° (50%) and 6 ° (60%) respectively. Thoracic Cobb: 70° posterior 61 ° anterior, corrected to 27° (61%) and 22° (64%) respectively. No difference in preoperative curve flexibility or fulcrum bending correction index. Thoracic AVT 55% correction posterior, 70% anterior, Lumbar Cobb 59% correction posterior, 52% anterior. Thoracic kyphosis significantly reduced in posterior surgery (35 ° to 20 °) and significantly increased with anterior surgery (21° to 30°). Lumbar lordosis significantly reduced with posterior surgery (88° to 47°), no significant change with anterior surgery (60° to 53°). MSRSI; Domain scores similar preoperatively between groups. Difference scores (postop-preop), higher scores=better. Pain: +1.21 posterior +0.73 anterior. Self image: +1.02 posterior +0.71 anterior. Function/activity: +0.28 posterior +0.21 anterior. Mental health: +0.66 posterior +0.45 anterior. No significant difference in complication rate, operative time or estimated blood loss. Similar cohorts of AIS patients treated by either anterior or posterior surgery have no significant differences in radiological or functional outcomes. The different final sagittal profile in both groups did not affect the MSRSI outcomes. Both procedures deliver significant health gains as measured by the MSRSI

Aims

Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems.

Aims

As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion.

Aims

Inflammatory response plays a pivotal role in the pathophysiological process of intervertebral disc degeneration (IDD). A20 (also known as tumour necrosis factor alpha-induced protein 3 (TNFAIP3)) is a ubiquitin-editing enzyme that restricts nuclear factor-kappa B (NF-κB) signalling. A20 prevents the occurrence of multiple inflammatory diseases. However, the role of A20 in the initiation of IDD has not been elucidated. The aim of the study was to investigate the effect of A20 in senescence of TNF alpha (TNF-α)-induced nucleus pulposus cells (NPCs).

The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make difficult decisions in the management of patients presenting with spinal metastases. A prospective cohort study of 199 consecutive patients presenting with spinal metastases, treated with either surgery and/or radiotherapy, was used to compare the three systems. Cox regression, Nagelkerke’s R² and Harrell’s concordance were used to compare the systems and find their best predictive items. The three systems were equally good in terms of overall prognostic performance. Their most predictive items were used to develop the Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient of determination than any of these three scores. A bootstrap procedure was used to internally validate this score and determine its prediction optimism.

The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and general condition (GC): OSRI = PTP + (2 – GC).

This simple score can predict life expectancy accurately in patients presenting with spinal metastases. It will be helpful in making difficult clinical decisions without the delay of extensive investigations.

Cite this article: Bone Joint J 2013;95-B:210–16.

In a retrospective cohort study we compared the clinical outcome and complications, including dysphagia, following anterior cervical fusion for the treatment of cervical spondylosis using either a zero-profile (Zero-P; Synthes) implant or an anterior cervical plate and cage. A total of 83 patients underwent fusion using a Zero-P and 107 patients underwent fusion using a plate and cage. The mean follow-up was 18.6 months (sd 4.2) in the Zero-P group and 19.3 months (sd 4.1) in the plate and cage group. All patients in both groups had significant symptomatic and neurological improvement. There were no significant differences between the groups in the Neck Disability Index (NDI) and visual analogue scores at final follow-up. The cervical alignment improved in both groups. There was a higher incidence of dysphagia in the plate and cage group on the day after surgery and at two months post-operatively. All patients achieved fusion and no graft migration or nonunion was observed.

When compared with the traditional anterior cervical plate and cage, the Zero-P implant is a safe and convenient procedure giving good results in patients with symptomatic cervical spondylosis with a reduced incidence of dysphagia post-operatively.

Cite this article: Bone Joint J 2013;95-B:543–7.