Background. Several theories have been put forward with respect to the mechanical role of the thoracolumbar fascia (TLF) but none have been substantiated in part due to an inability to explore its function in vivo. This study explored the use of ultrasound to image the layers of the TLF in vivo. Methods. Initially a cadaveric dissection of the fascia was performed to gain an appreciation of the 3-D orientation and representation of the TLF in the lumbar region. A conventional ultrasound system (Diasus, Dynamic Imaging Ltd) was then used to image the 3 layers of the fascia on 40 normal subjects (18 males and 22 females, mean age 27.3±5.8 years) and the reliability of these measures was investigated on a subset of this population. Results. Using ultrasound, the posterior and middle layer of the TLF could be readily identified, however it was not possible to visualise the anterior layer due to the limitations of the scanner used. The thickness of the posterior layer ranged from 1.3 ±0.4 to 1.5±0.4 mm depending on location relative to the spinous process. The middle layer tended to be thinner being 1.0±0.4mm on average. Intra-observer errors were within acceptable ranges, although not ideal. Conclusion. Ultrasound may be an important tool for understanding the mechanical role of fascia, however this would necessitate the use of high resolution scanner to enhance the reliability of images. Further work is required to image changes in the presentation of fascia in different loaded functional positions

Purpose. We present results of high intensity focussed ultrasound (HIFU) therapy on 2 patients with recurrent sacrococcygeal chordoma with the aim to promote recruitment of patients into a larger clinical trial. Method. Extracorporeal high intensity focussed ultrasound, outcome measure: radiological evidence of involution, clinical status at follow up. Sacrococygeal chordomas are rare, histologically benign tumours that tend to grow inexorably causing pain, and loss of function in the lower limbs and genitor-urinary symptoms. Results after surgical resection with conventional radiotherapy have been generally disappointing. Carbon ion therapy has been reported to be more successful, but this is not available in the UK. Both patients presented some years after surgical resection with recurrent sacral chordoma, causing intractable pain, and declining mobility. The patients underwent several (4 and 2) sessions of HIFU, using a protocol adapted for renal cell carcinoma and without any adverse events. Follow up MRI 2 weeks and 3 months post procedure showed reduction in tumour enhancement in targeted areas. This correlated with a patient-reported improvement in pain control and improving lower limb function sustained during a 3 month period. We propose the establishment of a clinical trial examining the utility of HIFU on recurrent sacral/coccygeal chordoma in adults after surgical resection. The outcomes measured will be pain scores, functional status using validated scoring scales to allow systematic comparisons with other treatments, and survival. We aim to recruit at least 14 patients initially. Side-effects and complications of the treatment will be recorded. Treatment and follow up of patients will take place in the Churchill Hospital, Oxford, UK

Magnetic Resonance Imaging (MRI) is the cornerstone investigation for cervical disc disease (CDD). However, MRI changes suggestive of CDD are found in people above forty, even in asymptomatic healthy individuals [1]. Mere presence of MRI changes of CDD does not exclude the presence of concomitant extra-foraminal pathology. No study design. We present here a series of three cases where use of ‘high resolution ultrasound’ has allowed accurate diagnosis of concomitant extra-foraminal pathology in patients with MRI-proven CDD. The three cases were acute neuropraxia of aberrant C5 nerve root, anterior interossous nerve compression due to pseudo-aneurysm of brachial artery and ‘acute brachial neuritis’ respectively. No outcome measure. Use of diagnostic high resolution ultrasound revealed accurate diagnosis of concomitant extra-foraminal pathology in all three cases. The cases with acute neuropraxia and acute brachial neuritis recovered with conservative treatment. Pseudo-aneurysm was treated successfully with surgery. High resolution ultrasound of the brachial plexus and peripheral nerves may be useful in following scenarios to identify an extra-foraminal pathology: (1) when symptoms and signs are out of proportion to the MRI findings of CDD; (2) when there is obvious discordance between MRI and nerve conduction findings; (3) where an entrapment neuropathy is suspected but the site of nerve lesion cannot be located

The purpose of this study was to ascertain whether early diagnosis through antenatal ultrasound screening and intervention lead to a reduction in morbidity associated with congenital scoliosis. Prospective cohort study. All fetuses with vertebral body anomalies detected over a thirteen years period were included. Maternal risk factors, accuracy of antenatal diagnosis, associated fetal anomalies and ultimate outcome are described. Twenty-four fetuses with congenital hemivertebrae were identified from 39,000 antenatal scans (incidence 0.061%). The mothers' median age at conception was 26 years (range 18-40 years). The median fetal gestational age at diagnosis was 20 weeks (range 18-38 weeks). The median gestational age at delivery was 38 weeks (range 27-40). Antenatal ultrasound identified eighteen fetuses with a single hemivertebra, six fetuses with multiple hemivertebrae. Eleven patients (50%) have undergone early surgical intervention with median post-natal follow up was 4 years (range 0-9 years). The median age at surgery was 12 months (range 1.2 - 47 months). The median pre-operative Cobb angle was 33 degrees and the median Cobb angle at final follow up was 25 degrees. In this series 50% of patients required surgical intervention. We felt that pre-natal diagnosis of congenital vertebra abnormally has resulted in early surgical intervention using less complex surgical technique to halt progressive deformity. However, further studies are required to compare the results with the abnormally not detected antenatally

Introduction. The main challenge in management of adolescent idiopathic scoliosis (AIS) is to predict which curve will progress so that appropriate treatment can be given. We previously reported that low bone mineral density (BMD) was one of the adverse prognostic factors for AIS. With advancement in imaging technology, quantitative ultrasound (QUS) becomes a useful method to assess bone density and bone quality. The objective of this study was to assess the role of QUS as a radiation-free method to predict curve progression in AIS. Methods. 294 girls with AIS were recruited at ages 11–16 years and followed up until skeletal maturity. 269 age-matched healthy girls were recruited as controls. They provided the normal reference for calculation of Z score for QUS parameters. QUS measurements, including BUA (broadband ultrasound attenuation), VOS (velocity of sound) and SI (stiffness index) of the calcaneum, BMD of femoral neck, menarche history, ages, and Cobb angle of the major curve were recorded at baseline as independent variables. The predictive outcome was curve progression defined as an increase of Cobb angle of 6° or more. Logistic regression model and the ROC curve were used for statistical analysis. Results. Mean follow-up was 3·4 years (SD 1·57). At baseline, mean age was 13·4 years (1·23), 73 (24·8%) patients were premenarchal, and mean Cobb angle was 26·3° (SD 8·2°). 202 (68·7%), 194 (66%), and 202 (68·7%) of patients with AIS had Z score of BUA, VOS, and SI of 0 or less, respectively. Initial univariate analysis indicated all independent variables had p values less than 0.2. Logistic regression analysis indicated that the p values of their regression coefficients were: age (p<0·001), menarchal status (p<0·001), Cobb angle (p=0·008), BMD (p=0·084), BUA (p=0·722), VOS (p=0·112), and SI (p=0·027). SI, age, menarchal status, and Cobb angle were therefore included in the final prediction equation. The adjusted odds ratio for Z score of SI of 0 or less was 2·00 (95% CI 1·08–3·71). The area under the ROC curve was 0·831(95% CI 0·785–0·877). The predictive model had a sensitivity of 0·847 and a specificity of 0·665 at a probability cutoff of 0·368. Conclusions. We recorded evidence of deranged bone density and bone quality in AIS, as indicated by QUS investigation. SI is an independent and significant prognostic factor for AIS. It can be used as a radiation-free parameter to predict curve progression in combination with initial Cobb angle, age, and menarchal status, especially when DXA is not available. Acknowledgments. This study is supported by Research Grant Council—The government of HKSAR (project number CUHK4498/06M)

Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’ symptoms and signs. Of note ‘bilateral sciatica’ had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed ‘low-risk’ of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. Conclusion. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677–682

Introduction. Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges. Methods. A retrospective analysis of cases from the Infectious Disease (ID) database with Extra Pulmonary Tuberculosis (EPTB) between 1. st. of January 2015 to 31. st. of January. Two groups were compared 1) Culture Negative TB (CNTB) and 2) Culture Positive TB (CPTB). Audit number was. Results. 31 cases were identified with EPSTB. 68% (n=21) were male. 55% (n=17) patients were Asian, (19% (n=6) were black and 16% (n=5) were of white ethnicity. 90.4% (n=28) patients presented with isolated spinal TB symptoms. No patient had evidence of HBV/HCV/HIV infections. CPTB Group was 51.6% (n=16) compared to CNTB Group with 48.4% (n=15) 48% (15) lumbar involvement, 42% (13) thoracic and 10% (3) cervical. 38.7% (12) patients presented with late neurology, equally in both groups. 56% CPTB patients showed signs of vertebral involvement on plain radiograph compared to 13.3% in CNTB patients. 68.7% CPTB patients had pathological changes or paraspinal collections seen on CT scan compared to 53.3% of CNTB patients. 81% of CPTB showed positive MRI findings compared to 86% in CNTB. Both groups were treated with Anti-TB medications according to local guidelines. 83% patients were followed up till the end of the treatment course. 22.5% (n=7) patients had Ultrasound guided aspiration. 29% (n=9) patients underwent surgical intervention. 3 patients had Laminectomy for decompression. 6 patients underwent Spinal Decompression and Fixation due to extensive bone destruction. No mortality occurred. Conclusion. TB continues to be a growing problem in the developed world with high numbers of patients travelling from endemic regions. 75% of our cases were from Asian or Black ethnicity. The thoracolumbar region was most commonly effected (90%). Approximately 50% of cases of extrapulmonary spinal TB were culture negative. Neurological deficit occurred in 40% patients and 30% of patients required surgery. Standard anti-TB treatment was however effective in all cases with no significant drug resistant variants noted. MRI and CT imaging remain the superior diagnostic tests in the presence of high CN EPSTB

SUMMARY. A retrospective cohort study of 19 patients of EOS who underwent MCGR rod instrumentation with subsequent serial distractions, measured using ultrasonography. The degree of distraction achieved during each session were analyzed and subgroup analysis done. HYPOTHESIS. The degree of distraction/ distractibility of the MCGR rod is closely linked to the etiology of EOS. The degree of distraction achieved at each session progressively diminishes with successive distractions. STUDY DESIGN. Retrospective cohort study. INTRODUCTION. MCGR rods have gained popularity as an alternative to traditional growing rods for the treatment of Early-onset scoliosis (EOS), serially distracting with an aim to mimic the normal spinal growth, which can be achieved in an outpatient setting using external remote controller. The use of ultrasound as a tool to measure the degree of distraction achieved has been validated previously. However the association between the etiological diagnosis of EOS and the degree of distraction achieved has not been studied previously. METHODS. We performed a retrospective cohort study of 19 patients with EOS of varying etiologies who underwent MCGR rod instrumentation at our institution since 2016. Their hospital records were analyzed to assess the demographics, distraction interval and the degree of distraction achieved at each session. RESULTS. 19 patients (12 females and 7 males) were included in the study. The average age of the study population was 7 years (4–13 years). The average follow up was 2.1 years (1–4). The following were the etiological diagnoses: Idiopathic EOS(8), Neuromuscular scoliosis(5), Syndromic(5), Congenital(1). The average interval between each distraction was 109.8days (88.2–140.6). The overall mean distraction was 1.66mm (0.6–3.427). The mean distraction achieved for the concave rod was 1.69mm (0.6–3.03) as against 1.59mm (0.2–3.427) for the convex rod. The degree of distraction achieved per session was the greatest in patients with neuromuscular scoliosis 2.79mm (0.94–4.62), while it was the least in Congenital scoliosis 0.99mm (0.8–2.93). The degree of distraction in Syndromic and Idiopathic scoliosis groups were 2.19mm (0.1–4.2) and 1.50mm (0.2–4.45) respectively. The mean distraction achieved during the first session after MCGR instrumentation was 2.82mm (0.4–9.8) as against 1.98mm (0.1–4.2) and 1.18mm (0.2–2.3), achieved during the 5. th. and 10. th. distractions respectively. CONCLUSIONS. The average distraction of the MCGR rod achieved per session depends upon the etiological diagnosis of EOS. Neuromuscular curves are the most amenable to MCGR distractions, while the congenital curves are the least. The degree of distraction achieved progressively diminishes with each successive distractions. The distraction achieved slumps to 70% of the initial distraction by the 5. th. session and further declines to 41% of the initial distraction by the 10. th. session. TAKE HOME MESSAGE. The distractibility of the MCGR rod is closely linked to the etiology of EOS. MCGR rods are most effective in cases of neuromuscular scoliosis, while least effective in congenital scoliosis. The law of diminishing returns holds true even with MCGR rods

Aim. To systematically review the literature and anatomical atlases on LM morphology. Methods. Relevant studies were searched in PubMed (Medline) and Science Direct. Anatomical atlases were retrieved from multiple university libraries and online. Included atlases and studies were assessed at five items: visuals present(y/n), quality of visuals(in-/sufficient), labelling of multifidus (y/n), clear description of region of interest(y/n), description of plane has been described(y/n). This risk of bias assessment tool was developed to assess the quality of description of anatomy, since existing risk of bias tables have only been developed to assess the methodology of studies. Results. In total 69 studies and 19 anatomical atlases were included. Studies. - 52 of 69 studies, LM was described as a superficial muscle at the levels L4 – S1. Others presented the LM as deep intrinsic muscle. - Most used methods: MRI, ultrasound imaging or drawings. - 32 of 69 studies scored a total of five points at the risk of bias assessment, which means low risk of bias. Anatomical atlases. - LM is shown as a deep intrinsic back muscle covered by the erector spinae and fascia thoracolumbalis. - Most anatomical atlases (8/19) had a score of four points at the risk of bias assessment. Conclusion. Anatomy atlases reported different LM morphology compared to anatomical studies. Even between studies, there appears to be inconsistent reporting in LM anatomy. Variation in research methods that are used for measuring LM morphology could influence variation in describing and presenting LM morphology. Standardization of research methodology is recommended in order to compare studies. No conflicts of interest. Sources of Funding: SIA RAAK-Publiek

Introduction. Developments in the use of ultrasound during pregnancy for assessment of fetal spine abnormalities indicate a need for accurate information about the antenatal development of the vertebral column. The published work is deficient in this regard, with available data examining only the period of 8–26 weeks. The aims of this study are to establish antenatal spine growth curves with fetal radiographs, to establish growth velocity curves for each anatomical spinal, region and to calculate the multiplier factor during antenatal life. Methods. 75 anteroposterior spine radiographs were retrieved from the fetal pathology unit. Cases with spinal anomalies were excluded from analysis. Individual vertebral regions were measured from radiographs with the method of Bagnall and colleagues,1 with use of DICOM software. Polynomial regression analysis was applied to each measurement with PASW statistics 18 (SPSS, Chicago, IL, USA). Results. 47 cases were included in the analysis. Gestational age ranged from 14–40 weeks. Growth velocity was greatest in the thoracic region and least in the sacral region. The table shows regression equations for each spinal region. Conclusions. Regression equations from this study will have direct clinical application in the antenatal ultrasound assessment of fetal maturity and normality, particularly the third trimester data. Use of the standard error of the estimate as an approximation to normal values will allow antenatal identification of anomalies, particularly in cases of scoliosis, spina bifida, and anencephaly

The purpose of this cohort study is to determine the incidence of all congenital vertebral anomalies detected antenatally through ultrasound. We also reported on the early mortality rate for this patient cohort, as well as the frequency and type of associated congenital anomalies. The East Midlands and South Yorkshire Anomalies Register consists of data on all voluntary reports of congenital anomalies, from an annual baseline birth rate of 67000 births. We analysed all registered congenital anomalies reported over a 10 year period. Between January 1997 and January 2007, 108 vertebral anomalies were reported, excluding spinal dysraphism (incidence 0.01%). 61 of these were detected antenatally (56%), 17 were detected postnatally (16%) and in 30 patients, the precise time of diagnosis was unclear (28%). At the time of analysis January 2007, 45 of 108 patients had died, either in utero or soon after delivery (42%). 12 fetuses remained in utero and 51 infants were alive. The mortality rate for antenatally diagnosed patients was 41% and the majority were electively terminated (72%). 2 fetuses electively terminated had vertebral anomalies in isolation. There is a relatively high incidence of elective termination of pregnancy as a result of antenatal anomaly ultrasound screening. We have evidence to suggest that foetuses with potentially minor congenital anomalies are being electively terminated at approximately 18 weeks gestation. A structured and timely spinal counselling should be offered once antenatal vertebral anomalies have been identified

Purpose of study. NICE recommends 8-9 sessions of non operative therapy for back pain that has lasted for 6 weeks but less than 12 months. NICE recommended exercises, manual therapy, acupuncture and suggested that Lumbar supports, TENS, Ultrasound and Traction should not be offered. Since multiple methods and disciplines were available a survey was conducted among the local General Practitioners to determine what non operative methods they preferred and how it matched with NICE's recommendation. Methods. An online survey was conducted on . www.surveymonkey.com. among the local GPs to determine their practice and preferences in investigating low back pain. The 5 questions in the survey were “rating scale questions” on a scale of 1 and 10, where 1 = DISAgree and 10 = Agree. A request to participate in the survey was sent to all the local General Practitioners by e-mail. Results. 25 General Practitioners participated in the survey. A sample of the scores obtained were as follows. Method of treatment. Mean Score. Mobilisation exercises. 8.20. Specific Core Stability Exercises. 8.13. Physiotherapy. 7.96. Pilates. 7.21. Attending a Gymnasium. 6.32. Medications. 6.20. Yoga. 6.18. TENS (Transcutaneous electrical nerve stimulation). 5.44. Acupuncture. 5.44. Chiropractory. 5.42. Osteopathy. 5.41. Massage. 4.73. Ultrasound. 3.43. Traction. 2.75. Lumbar support. 2.65. Conclusion. This limited study demonstrates that General Practitioners prefer patients to use active modalities of treatment like exercises which require participation of the patient rather than passive methods of treatment like lumbar support and massage. The choices of the GPs are nearly in tune with the recommendations of NICE with some exceptions. TENS (not recommended by NICE) obtained a better score than Acupuncture (recommended by NICE)

Aims

To benchmark the radiation dose to patients during the course of treatment for a spinal deformity.

Purpose and background:. Cauda Equina Syndrome (CES) is a rare condition which, even in the presence of prompt surgical decompression, can have devastating consequences for patients in terms of bladder and bowel dysfunction. The aim of this project was to develop a post-operative pathway for the assessment and management of bladder and bowel dysfunction in patients with CES. Method:. Beaumont Hospital performs a high volume of spinal surgeries. A small number are lumbar decompression surgeries due to CES. While sphincter function is routinely screened by a physiotherapist post-operatively, to date there has been no protocol in place for assessment and management of bladder and bowel dysfunction in this population. This project was carried out in collaboration with consultants in urology and colorectal surgery, as well as clinical nurse specialists in both areas. Results:. All patients undergoing lumbar decompression due to CES will be referred to a colorectal surgeon for post-operatively review and out-patient monitoring. A routine bladder ultrasound will be completed post-operatively to assess for urinary retention with a post void residual > 150 mls of urine indicating the need for referral to a urologist for in-patient review and out-patient follow-up. A patient education leaflet has also been developed. Conclusions:. A pathway has been implemented at Beaumont Hospital to ensure timely referral to specialised teams for both assessment and management of bladder and bowel dysfunction in CES. This pathway will ensure prompt access to specialised and supportive multi-disciplinary teams in the days/weeks/months/years post-operatively thereby minimising the emotional distress and health risks associated with secondary complications of CES

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

Aims

Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications.

Aims

We present a case series of five patients who had revision surgery following magnetic controlled growing rods (MGCR) for early onset scoliosis. Metallosis was found during revision in four out of five patients and we postulated a mechanism for rod failure based on retrieval analysis.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.