Antibiotics are often administrated prophylactically in spinal procedures to reduce the risk of infection of the disc space. It is still not known which antibiotics are able to penetrate the intervertebral disc effectively. In a prospective, randomised, double-blind clinical study, we examined the penetration of the intervertebral discs of two commonly used antibiotics, cefuroxime and gentamicin. The patients, randomised into two groups, received either 1.5 g of cefuroxime or 5 mg/kg of gentamicin prophylactically two hours before their intervertebral discs were removed. A specimen of blood, from which serum antibiotic levels were determined, was obtained at the time of discectomy.

Therapeutic levels of antibiotic were detectable in the intervertebral discs of the ten patients who received gentamicin. Only two of the ten patients (20%) who received cefuroxime had a quantifiable level of antibiotic in their discs although therapeutic serum levels of cefuroxime were found in all ten patients. Our results show that cefuroxime does not diffuse into human intervertebral discs as readily as gentamicin. It is possible that the charge due to ionisable groups on the antibiotics can influence the penetration of the antibiotics. We therefore recommend the use of gentamicin in a single prophylactic dose for all spinal procedures in order to reduce the risk of discitis.

Introduction. Reported incidence of DVT after spinal surgery ranges from 0-15% and PE 0.5-2.7%. Theoretically, manipulation of the vessels and venous stasis caused by retraction during anterior lumbar inter-body fusion may increase the propensity for thrombosis. The reported incidence of DVT and PE following major abdominal and pelvic surgery are high (up to 23%) and all these patients routinely receive chemical prophylaxis. Aim. Should patients undergoing ALIF surgery receive chemical prophylaxis routinely?. Materials and Methods. Retrospective review of ALIF procedures done between Jan 2007- Jan 2010. Review of case notes, radiology reports and telephone call to the patients to exclude DVT. Total of 76 patients underwent ALIF during this period. Forty six were female(60.5%) and 36 were 2 level fusions(47%). L5-S1 being commonly fused (76%) followed by L4-L5 (23%). Average surgical time from theatre records is 115 minutes(31-369 minutes). All patients received mechanical prophylaxis in the form of thigh length TED stockings. None of the patients were on treatment for DVT prior to surgery. Results. Three patients (3.9%) had Doppler proved DVT which required anticoagulation treatment. There was no reported incidence of PE. Discussion. There is no definite evidence in the literature to suggest ALIF surgery has higher incidence of thromboembolic complications, though theoretical possibility of increased risk. Current study suggests that incidence is 3.9% with mechanical prophylaxis alone which is very small when compared to incidence after major abdominal, pelvic or gynaecological procedures. Our small study sample suggests routine use of chemical prophylaxis to reduce the risk of DVT for anterior lumbar inter-body fusion is not justified

Purpose of Study. To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines. Methods. A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines. Results. Thirty specialised centres were contacted. Twenty eight centres followed NICE recommendations, with 2 centres using their own protocol. Four centres made changes to their existing protocols after the emergence of NICE guidelines. GCS (Graduated compression stockings) were uniformly used by all, with most centres using flowtron boots and/or foot in addition. The practices are differing within centres for elective versus trauma surgery. Of note, in patients with an acute cord injury, 20 centres used combined pre operative prophylaxis whereas 10 centres used only mechanical prophylaxis. Three units (10 %) describe a noticeable rise in complications related to chemoprophylaxis, whilst only one unit has reported a PE death within the last year. Discussion. Our survey assesses compliance to the NICE guidelines by the UK's spinal units. Mechanical prophylaxis appears to be the most common mode of prophylaxis understandably due to predictable safety profile. Use of chemo-prophylaxis varies amongst different surgeons and centres. Rather than a result of evidence based practice, the decision appears to be related to the previous experiences of that unit. Although the NICE guidelines provide a reasonable platform to the practice of thromboprophylaxis, more studies are required to evaluate the risks of thrombosis and bleeding events in spinal surgery

Aims. To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis. Patients and Methods. A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria. Results. In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI. Conclusion. A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204–9

Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has focused on VTE following joint arthroplasty their exists a gap in the literature examining the incidence of VTE in spinal surgery; with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, undertaken at the 2009 BASS Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery and to compare selections made by Orthopaedic and Neurosurgeons. We developed a questionnaire based around eight clinical scenarios. Participants were asked to supply details on their speciality (orthopaedics or neurosurgery) and level of training (grade) and to select which method(s) of thromboprophylaxis they would employ for each scenario. Thirty-nine participants provided responses to the eight scenarios; complete details, including speciality and grade of those surveyed, were complied for 27 of the 39 questionnaires completed. LMWH was the preferred pharmacological method of thromboprophylaixs selected 31% and 72% of the time by orthopaedic and neurosurgeons respectively. For each of the eight clinical scenarios LMWH and BK TEDS were selected more frequently by neurosurgeons than orthopaedic surgeons who elected to employ early mobilisation and mechanical prophylaxis. Neurosurgeons were more likely to employ more than method of thromboprophylaxis. Thromboprophylactic selections differed between the two groups; Neurosurgeons preferred LMWH and BK TEDS whilst Early Mobilisation and Mechanical prophylaxis were the preferred methods of thromboprophylaxis amongst orthopaedic surgeons. Based on the results of this survey neurosurgeons more closely adhered to guidelines outlined by NICE/BASS

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The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption.

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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.

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

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Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

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To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

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To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII).

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The aim of this study was to determine whether the sequential application of povidone iodine-alcohol (PVI) followed by chlorhexidine gluconate-alcohol (CHG) would reduce surgical wound contamination to a greater extent than PVI applied twice in patients undergoing spinal surgery.

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The purpose of this prospective study was to evaluate the outcomes of coccygectomy for patients with chronic coccydynia.

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In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

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.

Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth.

We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion.

The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.