Aims

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Background. Low back pain (LBP) is widespread in all populations and is a worldwide health problem, which poses substantial challenges for clinical management. Individuals with LBP may reduce their symptoms by implementing self-managed at-home interventions. The theoretical design of the LumbaCurve™ promotes the principles of a passive gravity-assisted traction (PGAT) stretch of the lumbar and sacral region in order to reduce LBP. This study aimed to assess the clinical effectiveness of the LumbaCurve™ in the management of LBP when compared to a control group of standardised care. Methods. Following a screening form using Red Flags and STarT Back tools, 60 individuals with LBP were recruited to the 4-week intervention. Eligible participants completed a pre-intervention questionnaire and were randomly allocated to either ‘standardised care’ or ‘standardised care PLUS LumbaCurve™’ group. Intervention material was trialled for 4 weeks consecutively, followed by a post-intervention questionnaire. Pre and post assessments applied the Roland Morris Disability Questionnaire (RMDQ), Patient Reported Outcome Measures (PROMS). Results. Interim results suggested RMDQ values demonstrate a trend toward the classification of ‘definite improvement’ following standardised care plus LumbaCurve™ intervention. When comparing pre/post outcomes alone for the intervention of standardised care plus LumbaCurve™, significant reductions in RMDQ results occurred (p=.014). PROMS results reported a significant decrease (p=.015) in average pain rating when comparing interventions. Conclusion. Initial findings report that through a four week intervention programme, significant improvements in patient reported back pain levels are demonstrated following standardised care plus LumbaCurve™ intervention. This abstract has not been previously published in whole or substantial part and has not been previously presented at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: Spark Ventures UK

Purpose. To evaluate the complications following percutaneous balloon kyphoplasty and assess the advantage of introducing eggshell technique. Methods and Results. We performed 138 Balloon kyphoplasty procedures in 85 patients during august 2007 to march 2010. Data was collected and analyzed in all these cases. Gender distribution was 60 females and 25 males. Age distribution was 33 to 85 years, with an average age of 67.4 years. Indications of surgery were vertebral fractures due to osteoporosis in 81% of the procedures, trauma in 13% and malignancy in 6%. The most common vertebral levels of the kyphoplasty were at T12 in 32 procedures (23%) and L1 in 28 procedures (20%). Eggshell technique was introduced in 2009 where technical problems were encountered during cementing process. All patients had reduced pain levels, which was assessed by visual analog score. The average length of hospital stay was 2.5 days. Complications were 9 (6.5%) cement leaks (all within one cm from the vertebral body) in procedures performed before the introduction of eggshell technique and no cement leak following the introduction of eggshell technique, 5 (3.6%) fresh fractures, 2 (1.4%) intra-operative fractures and 1 (0.73%) rupture of balloon. There were no complications of cord compression, motor deficit, infection, allergy to cement or pulmonary embolism noted. 30-day mortality rate was zero. Conclusion. Our series had 6.5% incidence of cement leak compared to 11-21% quoted in current literature. Since the introduction of eggshell technique, cement leak rate was reduced to zero%. Hence adopting of eggshell technique during percutaneous balloon kyphoplasty procedure may eliminates the risk of cement leak thereby minimizing complications

Background. Social context may be important in chronic pain. One focus is reactions to pain between persons with LBP and their partners. Researchers have investigated partner reactions and found influences on pain levels and psychological outcomes, but little is known about factors underpinning these reactions. Aim. To investigate the associations of relationship quality and perceived partner responses with LBP intensity and disability. Method. Participants with partners (n=174) in a cohort study of LBP in primary care were included. Data on pain intensity, disability (RMDQ), perceptions of negative or solicitous partner responses (MPI), relationship quality (RDAS) and depression and anxiety (HADS) was collected. Results. Consensus (e.g. agreement about affection and sex) and satisfaction (frequency of arguments/disagreements) were significantly associated with pain intensity (p 0.01 and p 0.02). Solicitous partner responses (e.g. providing comfort, physical assistance) were significantly associated with patient disability (p 0.04). These significant associations only became apparent when depression was entered into the model, suggesting effect modification. Stratification by depression revealed associations between consensus and pain among those with high depression levels (p 0.04) and associations between solicitousness and disability in those with low depression levels (p 0.01). Overall, the models accounted for 14-17% of the variance in pain intensity and 26-29% of the variance in disability. Conclusion. Results show associations of solicitousness, satisfaction and consensus with pain intensity and disability. However the effect varies by the presence of depression. Further research should investigate further the pathway of relationship quality, depression and pain

Purpose. This pilot study tested the feasibility of a self-determination theory-based communication skills training programme designed to increase physiotherapists' psychological needs supportive behaviour when treating patients with chronic low back pain (CLBP>12 weeks). Methods. Both control (n = 4) and intervention (n = 3) physiotherapists received one hour of evidence-based CLBP management education. Intervention group physiotherapists also received six hours of autonomy-support training, utilizing the ‘5A’ health behaviour change model. Consenting participants [intervention n=16, mean (SD) age = 49.00 years (14.91); control n=12, mean (SD) age = 43.42 (11.70yrs)] completed the primary [self-reported PA, adherence to prescribed exercises, pain, disability, satisfaction] and secondary outcomes [psychological needs support, autonomous motivation, competence] at Week 1 and at Week 4. Results. Compared with controls, intervention group participants reported more PA (d = .26 in Week 1, d = .50 in Week 4), greater adherence to home exercises (d = .40 in Week 1, d = .15 in Week 4) and larger improvements in satisfaction (d = .41). Decreases in pain levels were similar in both groups and improvements in functional outcomes were less for the intervention group (d =. 25), who also reported similar or higher levels of autonomy support (d = .24 in Week 1, no difference in Week 4), autonomous motivation (no difference in Week 1, d = .21 in Week 4), and perceived competence (d = .32 in Week 1, d = .46 in Week 4). Conclusion. Findings provided preliminary evidence supporting the feasibility of this intervention and a fully powered RCT is planned

We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months. The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing. The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity. Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass

Aims

The aim of this study was to compare the effect of a percutaneous radiofrequency heat lesion at the medial branch of the primary dorsal ramus with a sham procedure, for the treatment of lumbar facet joint pain.

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients.

Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction.

The optimal timing of percutaneous vertebroplasty as treatment for painful osteoporotic vertebral compression fractures (OVCFs) is still unclear. With the position of vertebroplasty having been challenged by recent placebo-controlled studies, appropriate timing gains importance.

We investigated the relationship between the onset of symptoms – the time from fracture – and the efficacy of vertebroplasty in 115 patients with 216 painful subacute or chronic OVCFs (mean time from fracture 6.0 months (sd 2.9)). These patients were followed prospectively in the first post-operative year to assess the level of back pain and by means of health-related quality of life (HRQoL). We also investigated whether greater time from fracture resulted in a higher risk of complications or worse pre-operative condition, increased vertebral deformity or the development of nonunion of the fracture as demonstrated by the presence of an intravertebral cleft.

It was found that there was an immediate and sustainable improvement in the level of back pain and HRQoL after vertebroplasty, which was independent of the time from fracture. Greater time from fracture was associated with neither worse pre-operative conditions nor increased vertebral deformity, nor with the presence of an intravertebral cleft.

We conclude that vertebroplasty can be safely undertaken at an appropriate moment between two and 12 months following the onset of symptoms of an OVCF.

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Between 1993 and 2008, 41 patients underwent total coccygectomy for coccydynia which had failed to respond to six months of conservative management. Of these, 40 patients were available for clinical review and 39 completed a questionnaire giving their evaluation of the effect of the operation. Excellent or good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with coccydynia due to trauma, five of the eight patients with symptoms following childbirth and ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although none described worse pain after the operation. The only post-operative complication was superficial wound infection which occurred in five patients and which settled fully with antibiotic treatment. One patient required re-operation for excision of the distal cornua of the sacrum.

Total coccygectomy offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms.

The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach.

There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion.

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth.

The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.