Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

Background: Clinical trials of surgery increasingly use disability and quality of life scales as their primary outcome measures. As such, they are the central dependent variables on which treatment decisions are based. It is therefore essential that these scales provide clinically meaningful and scientifically sound (reliable and valid) measurements.

Aim: The aim of this study was to determine if three scales used widely for spinal surgery (the Short form 36 item health survey – SF-36, Oswestry and Neck Disability Indices – ODI, NDI) satisfied basic requirements for reliable and valid measurement, and if they were suitable to detect clinically significant change.

Method: We analysed data from 147 people undergoing cervical (SF-36, NDI), and 233 people undergoing lumbar (SF-36, ODI) spine surgery. We tested the full range of measurement properties of these scales. These included the assumption that adding up items generates meaningful scores and, if that test was passed, scale targeting to study samples, reliability, validity and responsiveness.

Results: In both samples, the SF-36 had problems. Some scales had notable floor and ceiling effects. As a consequence they were unable to detect change. Other scales failed validity tests. Importantly, there was no support for using SF-36 summary scores in either cervical or lumbar surgery. With the ODI and NDI, there were problems with the individual questions. Specifically, the item response options were not working as anticipated. This compromises the reliability and validity of both scales.

Conclusions: This study, whose aim was to assess three scales used to evaluate surgery, not the surgery itself, demonstrates that all three have important limitations and questions their suitability for this crucial role. Essentially, all three scales give inaccurate estimates of treatment effectiveness. The result is that the benefits of spinal surgery are almost certainly being under-evaluated and spinal surgeons are selling themselves short.

Introduction: In order to improve the provision of Spinal Surgery in the United Kingdom, the number of Specialist Spinal Surgeons and Surgeons with an Interest in Spinal Surgery needs to increase by 25% from the existing 175 surgeons. There is an expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery not only to maintain the status quo, with one third of Specialist Spinal Surgeons due to retire in the next three years, but also to provide the needed expansion in numbers. Methods and results: A postal survey of the 528 SpRs was performed with a response rate fo 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery. Sixty-nine per cent indicated that they intended to avoid all Spinal Surgery. Thirty-five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only nine (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first two years of training, to 70% in the middle two years, and to 75% in the final two years and post C.C.S.T. fellowships. There should be 24 newly accredited Specialist Spinal Surgeons based on a projection of the 4.3% response intending to become Specialist Spinal Surgeons. This leaves a shortfall of 34 Specialist Spinal Surgeons by 2005. The survey has revealed three main features of Spinal Surgery which appear to have a negative effect on the attitude of the SpRs to Spinal Surgery and overwhelm the potentially attractive features. These are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to Spinal Surgery during their training. Conclusion: It is clear from the response of SpRs that there are important misconceptions concerning Spinal Surgery, together with the shortcomings of training and of the provision of services within the NHS. These have to be addressed urgently if the speciality is to become more attractive to them. Areas where positive action can be taken include the modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and above all the need for Spinal Surgeons to be encouraging and enthusiastic about a field of surgery which provides some of the exciting challenges in Orthopaedic Surgery

To quantify the expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery with one third of Specialist Spinal Surgeons due to retire in the next 3 years and to provide the needed expansion of 25% in the existing number of 175 surgeons. A postal survey of the 528 SpRs was performed with a response rate of 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery. Sixty nine percent indicated that they intended to avoid all Spinal Surgery. Thirty five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only 9 (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first 2 years of training, to 70% in the middle 2 years, and to 75% in the final 2 years and post CCST fellowships. Based on a projection of the 4. 3% response intending to become Specialist Spinal Surgeons there will be a shortfall of 34 Specialist Spinal Surgeons by 2005. The features of Spinal Surgery which appear to have a negative affect and overwhelm the potentially attractive features are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to spinal surgery during SpR training. The modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and a need for Spinal Surgeons to be encouraging and enthusiastic about this field of surgery are essential

Aims. Informed patient consent is a legal prerequisite endorsed by multiple regulatory institutions including the Royal College of Surgeons and the General Medical Council. It is also recommended that the provision of written information is available and may take the form of a Patient Information Leaflet (PIL) with multiple PILs available from leading orthopaedic institutions. PILs may empower the patient, improve compliance, and improve the patient experience. The national reading age in the United Kingdom is less than 12 years and therefore PILs should be written at a readability level not exceeding 12 years old. We aim to assess the readability of PILs currently provided by United Kingdom orthopaedic institutions. Patients and Methods. The readability of PILs on 58 common conditions provided by seven leading orthopaedic associations in January 2017, including the British Orthopaedic Association, British Hip Society, and the British Association of Spinal Surgeons, was assessed. All text in each PIL was analyzed using readability scores including the Flesch–Kincaid Grade Level (FKGL) and the Simple Measure of Gobbledygook (SMOG) test. Results. The mean FKGL was 10.4 (6.7 to 17.0), indicating a mean reading age of 15 years. The mean SMOG score was 12.8 (9.7 to 17.9) indicating a mean reading age of 17 years. Conclusion. Orthopaedic-related PILs do not comply with the recommended reading age, with some requiring graduate-level reading ability. Patients do not have access to appropriate orthopaedic-related PILs. Current publicly available PILs require further review to promote patient education and informed consent. Cite this article: Bone Joint J 2018;100-B:1253–9

Many hospitals do not have a structured process of consent, the attainment of which can often be rather ‘last-minute’ and somewhat chaotic. This is a surprising state of affairs as spinal surgery is a high-risk surgical specialty with potential for expensive litigation claims. More recently, the Montgomery ruling by the United Kingdom Supreme Court has placed the subject of informed consent into the spotlight. . There is a paucity of practical guidance on how a consent process can be achieved in a busy clinical setting. The British Association of Spinal Surgeons (BASS) has convened a working party to address this need. To our knowledge this is the first example of a national professional body, representing a single surgical specialty, taking such a fundamental initiative. . In a hard-pressed clinical environment, the ability to achieve admission reliably on the day of surgery, in patients at ease with their situation and with little likelihood of late cancellation, will be of great benefit. It will reduce litigation and improve the patient experience. Cite this article: Bone Joint J 2016;98-B:1427–30

Aims. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

There is no universally agreed definition of cauda equina syndrome (CES). Clinical signs of CES including direct rectal examination (DRE) do not reliably correlate with cauda equina (CE) compression on MRI. Clinical assessment only becomes reliable if there are symptoms/signs of late, often irreversible, CES. The only reliable way of including or excluding CES is to perform MRI on all patients with suspected CES. If the diagnosis is being considered, MRI should ideally be performed locally in the District General Hospitals within one hour of the question being raised irrespective of the hour or the day. Patients with symptoms and signs of CES and MRI confirmed CE compression should be referred to the local spinal service for emergency surgery. CES can be subdivided by the degree of neurological deficit (bilateral radiculopathy, incomplete CES or CES with retention of urine) and also by time to surgical treatment (12, 24, 48 or 72 hour). There is increasing understanding that damage to the cauda equina nerve roots occurs in a continuous and progressive fashion which implies that there are no safe time or deficit thresholds. Neurological deterioration can occur rapidly and is often associated with longterm poor outcomes. It is not possible to predict which patients with a large central disc prolapse compressing the CE nerve roots are going to deteriorate neurologically nor how rapidly. Consensus guidelines from the Society of British Neurological Surgeons and British Association of Spinal Surgeons recommend decompressive surgery as soon as practically possible which for many patients will be urgent/emergency surgery at any hour of the day or night. . Cite this article: Bone Joint J 2015;97-B:1390–4

Introduction: In 1998 the British Scoliosis Society was asked by the Board of Affiliated Societies to the BOA to provide information concerning the activity, numbers and training implications for specialists in our field. We had no systematic data so with the valuable assistance of the BOA a survey of spinal surgery activity was undertaken amongst 187 Orthopaedic Surgeons who had declared spinal surgery as a main interest in a previous BOA survey. One hundred and fifty questionnaires were returned (80.2%). This data was collated and analysed by the Statistical Department of the British Orthopaedic Association. As a result of the information obtained a template for the organisation of management of spinal disorders in UK and its manpower implications was developed. This template was then circulated to the Presidents of all the British Spine Societies for consideration at their AGMs in 1999. There was widespread support. It is understood that the BOA have also discussed these proposals along with those from other affiliated societies and it is perhaps time for further action. Methods and results: The results from the postal questionnaires were analysed along with information from other sources. Fifty-five surgeons were identified as being Specialist Spinal Surgeons (greater than 70% of their time), 120 Surgeons were designated Surgeons With An Interest (greater than 30% of their time), 25 Surgeons spent less than 30% of their time on spines. Sixty-two per cent (93 Surgeons) considered their facilities for spinal work were adequate, 34.7% (52) considered that they were inadequate and 3.3% (5) said that they were unacceptable. Forty-nine per cent (73) of those responding employed a triage system with 58.5% using a physiotherapist and 16.2% using a nurse. Five point nine per cent used a clinical assistant and 19.1% of triage was done by the Spinal Surgeon. Regarding outpatient waiting times, 31% of Surgeons had a waiting time of three to six weeks for urgent appointments with 20% longer than six weeks. Sixty per cent had a waiting time of over six months for non urgent consultations. For urgent but not emergency surgery 70% had a waiting time of over three weeks and half of those were over six weeks. For non urgent spinal surgery 70% were waiting more than six months with 50% waiting more than nine months. Conclusion: Our limited manpower and resources must be used with maximum efficiency while we wait for the inevitably slow build up to international best practice which is likely to take at least ten years with a fair wind. The Template: 20 Regional Spine Centres each with at least five Specialist Spinal Surgoens (SSS) including one or two Neurosurgeons, total 100 Surgeons. Sixty-five District Spine Centres (at least three per Region) with at least two Surgeons With An Interest (SWI) (Orthopaedic or Neuro), total 130 Surgeons. At present we have 55 SSS of whom 18 will be retired by 2005. We have around 120 SWI of whom only nine will be retired in 2005 taking retirement age at 65. We therefore have a shortfall of 63 SSS and perhaps 10 SWI a number of whom may wish to upgrade to SSS. According to Okafor and Sullivan (1998) the average European country of our size would have 150 SSS compared with our 55. 1.There is an urgent need for more Orthopaedic Surgeons and in particular Spinal Surgeons. 2.Surgeons need adequate facilities and infrastructure to allow them to work efficiently. Finance is required. 3. Until the training base for future Specialists involved in the management of spinal disorders is steadily expanded from bottom to top, little progress can be expected

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Objective: To assess the cardiology of continuous ECG of Spinal Surgeons performing complex spinal deformity surgery. Design: Spinal surgeons were attached to 24 hour tape ECG monitors while performing spinal deformity surgery. Pre op, intra-op and immediate post op assessment were performed. Subjects: 4 Consultants 1 Spinal Fellow. Outcome measures: ECG changes, Heart Rate variance and Heart Rate. Results: Variability in Heart rate was related to the experience of the surgeon and the case performed. Heart rate variance was highest in the Consultant with the most recent appointment. Heart rate variance in the Trainee was the lowest. The highest heart rate was achieved when scrubbed supervising the surgical trainee. The surgeons with the highest deformity work load had the lowest intra-operative heart rate. Conclusions: Spinal deformity surgery is stressful to the Consultant performing the case. Experience and case mix affect these findings. The highest stress rate occurs with supervising trainees

Objectives: To surgery the UK Specialist Orthopaedic Registrars (SpRs) to assess their perceptions of and attitudes towards spinal surgery, and to identify factors discouraging interest in spinal surgery. Introduction: In order to improve the provision of spinal surgery in the UK, the existing 175 Orthopaedic Surgeons with an interest in Spinal Surgery needs to increase by 25%. There is a predicted shortfall in the number of orthopaedic trainees intending to practise spinal surgery. Methods: A postal questionnaire was sent to all 578 SpRs. Results: Three hundred and seventy-four replied (71%). Sixty-nine percent intend to avoid spinal surgery. Thirtyfive (9%) intend becoming either Specialist Spinal Surgeons or Surgeons with a Spinal interest. Their perceptions will be discussed; the intellectual challenge and opportunities for research are widely recognised but are outweighed by poor perceptions of outcomes of surgery, psychological complications, and of badly organised clinics. There is also inadequate exposure to spinal surgery during training. Conclusions: Training in spinal surgery could be improved by exposure to spinal surgery at an earlier stage of training, and the development of more specialised units with properly structured spinal clinics to include triage systems to assess referrals and close liaison between the specialities required to treat these patients

The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

This study sought to determine the post-operative management of spinal patients in the UK, and to determine if uniformity exists between surgeons and if there is any published evidence for this practice. A reply-paid questionnaire was sent to members of the British Association of Spinal Surgeons and the Society for Back Pain Research. The questionnaire documented the surgeon’s experience, where they work, their operative population, the types of spinal surgery performed, and whether they have a routine for post-operative management or any written instructions for patients concerning post operative management. It also asked about the nature and duration of professionally supervised rehabilitation. Of the 89 questionnaires distributed, 63 (71%) were returned, of which 51 could be used in the analysis. The 12 not used were either completed incorrectly, had missing data or the surgeon had since retired. The replies demonstrated wide variation: only 35% of surgeons provide their patients with written post-operative instructions; there was limited referral to physiotherapy, with only 45% referring to a physiotherapist (for an average of 1.8 sessions); only a modest fraction of surgeons advocated the use of a post-operative corset (18%), others restricting sitting or encouraging bed rest; and a range of recommendations regarding return to work. There was also only a limited correlation between restrictions on sitting and recommendations about return to sedentary work or driving (Spearman r=0.08 and 0.36, respectively). In summary, although individual surgeons may be certain of their practice, the overall variation indicates ongoing uncertainty across the profession. This was further substantiated by our literature search, which revealed limited evidence for current practices, and a paucity of research into postoperative management

Introduction: (1) Determine whether initial MRI findings correlate with clinical outcome.(2) Study the reproducibility of MRI measurements of large disc prolapses.(3) Estimate the ability to predict CES based on MRI alone.(4) Does CES only occur in degenerate discs?. Method: 31 patients with CES were identified and invited to attend clinic. 19 patients who underwent discectomy were identified. Digital photographs of all 50 MRIs were obtained. Observers: 1 Radiologist, 2 Spinal Surgeons and 1 Trainee did not know the number of patients in each group. Observers estimated the percentage spinal canal compromise on each view (0–100%), indicated whether they thought the scan findings could produce CES and commented on disc degeneration. Measurements were repeated after 2 weeks. Results: 26 patients attended clinic – mean follow up 51 months (range 25–97). 12 of the 26 patients with CES had, on average, > 75% canal compromise. No significant correlations were found between MRI canal compromise and clinical outcome. Kappa values for intra-observer reproducibility of measurements ranged from 0.4–0.85 and inter-observer 0.63–5. Based on MRI, the correct identification of CES has sensitivity 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%. Over 80% of the CES causing discs were degenerate. Discussion: Canal compromise does not appear to predict clinical outcome. MRI measurement reproducibility has substantial agreement. CES is a clinical diagnosis supported by an MRI scan. In less clear cases the presence of a large disc on an MRI scan supports a diagnosis of CES (PPV 84%). CES occurs in degenerate discs

Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

Introduction: Current evidence suggests CES should be operated < 48 hours from onset. MRI scanning is often not available 24 hours a day. Objectives: (1) Determine whether MRI findings correlate with clinical outcome. (2) Study the reproducibility of MRI measurements of large disc prolapses. (3) Estimate the ability to predict CES based on MRI alone. Study Design: 31 CES patients were identified,contactedand invited to follow up. Clinical outcome consisted of history and examination, and validated questionnaire assessments. 19 patients who underwent discectomy were identified. T2 mid-sagittal and axial digital photographs of all 50 MRIs were obtained. Observers did not know the number of patients in each group (1 Consultant Radiologist, 2 Consultant Spinal Surgeons and 1 SHO). They estimated the percentage spinal canal compromise on each view (0–100%) and indicated whether they thought the scan findings could produce CES. Measurements were repeated after 2 weeks. Results: 26 patients attended clinic (mean follow up 51 months). There were no significant correlations found between MRI canal compromise and clinical outcome. Kappa values for the measurements ranged 0.52–0.85 and 0.61–0.75 for intra- and inter-observer reproducibility. Based on MRI alone correct identification of CES has sensitivity 67%, specificity 81%, positive predictive value 85% and negative predictive value 60%. Conclusions: Canal compromise on MRI does not predict the outcome of patients with CES. Reproducibility of MRI measurements of large disc protrusions has substantial agreement. MRI could be of help in equivocal cases if the scan shows a large disc

Introduction: Current evidence suggests that CES should be operated within 48 hours from onset of sphincteric symptoms in order to maximise chances of recovery. Measurement reproducibility of large disc prolapses and clinical correlations have not previously been studied. Objectives: (1) Determine whether initial MRI findings correlate with clinical outcome (2) Study the reproducibility of MRI measurements of large disc prolapses (3) Estimate the ability to predict CES based on MRI alone. Study Design: 31 patients with CES were identified, the case notes reviewed and the patients invited to attend clinic. Outcome consisted of history and examination, and several validated questionnaire assessments. 19 patients who underwent discectomy for persistent radiculopathy were identified. None had sphincteric symptoms. All had a significant surgical target. Digital photographs of all 50 MRIs were obtained showing the T2 mid-sagittal image and the axial image with the greatest disc protrusion. The Observers: 1 Consultant Radiologist, 2 Consultant Spinal Surgeons and 1 SHO did not know the number of patients in each group. Observers estimated the percentage spinal canal compromise on each view and indicated whether they thought the scan findings could produce CES. Measurements were repeated after 2 weeks. Results: 26 patients attended clinic mean follow up 51 months (25 to 97). As expected, the % canal compromise differed significantly between the two groups (p0.001). 12 of the 26 patients with CES had, on average, over75% canal compromise. No significant correlations were found between MRI canal compromise and clinical outcome. Canal compromise did predict whether the patient would fail their Trial Without Catheter (p0.05). Based on MRI alone, the correct identification of CES has sensitivity 68%, specificity 78%, positive predictive value 84% and negative predictive value 58%. Kappa values for intra-observer reproducibility ranged from 0.4 to 0.85 for sagittal compromise, axial compromise and correct prediction of CES. All three interobserver kappa values for these measurements were 0.64. Conclusions: This is the largest radiological case series of CES with 4 years clinical follow up. Canal compromise on MRI does not appear to directly predict clinical outcome. Reproducibility of MRI measurements of large disc protrusions has substantial agreement. MRI could be of help in equivocal cases if the scan shows a large disc

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of “failure to warn”, i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on “failure to warn” and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA.

Cite this article: Bone Joint J 2020;102-B(5):550–555.

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery.

Cite this article: Bone Joint J 2019;101-B:355–360.