Aims. Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted. Methods. As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients. Results. Of the 90 patients screened, 77 passed the initial screening criteria. A total of 27 patients had a PI-LL mismatch and 23 had a dynamic spondylolisthesis. Following secondary inclusion and exclusion criteria, 31 patients were eligible for the study. Six patients were randomized and one underwent surgery during the study period. Given the low number of patients recruited and randomized, it was not possible to assess completion rates, quality of life, imaging, or health economic outcomes as intended. Conclusion. This study provides a unique insight into the prevalence of dynamic spondylolisthesis and PI-LL mismatch in patients with symptomatic spinal stenosis, and demonstrates that there is a need for a definitive RCT which stratifies for these groups in order to inform surgical decision-making. Nonetheless a definitive study would need further refinement in design and implementation in order to be feasible. Cite this article: Bone Jt Open 2023;4(8):573–579

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery. The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression. Cite this article: Bone Joint J 2013;95-B:1388–91

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

Aims. To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability. Methods. This was a cross-sectional study of 2,206 subjects along with L1-S1 axial and sagittal MRI. Clinical and radiological information regarding their demographics, workload, smoking habits, anteroposterior (AP) vertebral canal diameter, spondylolisthesis, and MRI changes were evaluated. Mann-Whitney U tests and chi-squared tests were conducted to search for differences between subjects with and without DSS. Associations of LBP and radicular pain reported within one month (30 days) and one year (365 days) of the MRI, with clinical and radiological information, were also investigated by utilizing univariate and multivariate logistic regressions. Results. Subjects with DSS had higher prevalence of radicular leg pain, more pain-related disability, and lower quality of life (all p < 0.05). Subjects with DSS had 1.5 (95% confidence interval (CI) 1.0 to 2.1; p = 0.027) and 1.8 (95% CI 1.3 to 2.6; p = 0.001) times higher odds of having radicular leg pain in the past month and the past year, respectively. However, DSS was not associated with LBP. Although, subjects with a spondylolisthesis had 1.7 (95% CI 1.1 to 2.5; p = 0.011) and 2.0 (95% CI 1.2 to 3.2; p = 0.008) times greater odds to experience LBP in the past month and the past year, respectively. Conclusion. This large-scale study identified DSS as a risk factor of acute and chronic radicular leg pain. DSS was seen in 6.9% of the study cohort and these patients had narrower spinal canals. Subjects with DSS had earlier onset of symptoms, more severe radicular leg pain, which lasted for longer and were more likely to have worse disability and poorer quality of life. In these patients there is an increased likelihood of nerve root compression due to a pre-existing narrowed canal, which is important when planning surgery as patients are likely to require multi-level decompression surgery. Cite this article: Bone Joint J 2021;103-B(1):131–140

Aims. The aim of this study was to determine the influence of developmental spinal stenosis (DSS) on the risk of re-operation at an adjacent level. Patients and Methods. This was a retrospective study of 235 consecutive patients who had undergone decompression-only surgery for lumbar spinal stenosis and had a minimum five-year follow-up. There were 106 female patients (45.1%) and 129 male patients (54.9%), with a mean age at surgery of 66.8 years (. sd. 11.3). We excluded those with adult deformity and spondylolisthesis. Presenting symptoms, levels operated on initially and at re-operation were studied. MRI measurements included the anteroposterior diameter of the bony spinal canal, the degree of disc degeneration, and the thickness of the ligamentum flavum. DSS was defined by comparative measurements of the bony spinal canal. Risk factors for re-operation at the adjacent level were determined and included in a multivariate stepwise logistic regression for prediction modelling. Odds ratios (ORs) with 95% confidence intervals were calculated. Results. Of the 235 patients, 21.7% required re-operation at an adjacent segment. Re-operation at an adjacent segment was associated with DSS (p = 0.026), the number of levels decompressed (p = 0.008), and age at surgery (p = 0.013). Multivariate regression model (p < 0.001) controlled for other confounders showed that DSS was a significant predictor of re-operation at an adjacent segment, with an adjusted OR of 3.93. Conclusion. Patients with DSS who have undergone lumbar spinal decompression are 3.9 times more likely to undergo future surgery at an adjacent level. This is a poor prognostic indicator that can be identified prior to index decompression surgery

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries. By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?. Retrospective study. We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted. The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°. In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level

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We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

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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).

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Degenerative cervical spondylosis (DCS) is a common musculoskeletal disease that encompasses a wide range of progressive degenerative changes and affects all components of the cervical spine. DCS imposes very large social and economic burdens. However, its genetic basis remains elusive.

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The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

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The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

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The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery. . Cite this article: Bone Joint J 2014;96-B:641–5

We evaluated 30 patients with cervical myelopathy before and after decompressive surgery and compared them with 42 healthy controls. All were asked to grip and release their fingers as rapidly as possible for 15 seconds. Films recorded with a digital camera were divided into three files of five seconds each. Three doctors independently counted the number of grip and release cycles in a blinded manner (N1 represents the number of cycles for the first five-second segment, N2 for the second and N3 for the third). N2 and N3 of the pre-operative group were significantly fewer than those of the control group, and the postoperative group’s results were significantly greater than those of the pre-operative group. In the control group, the numbers decreased significantly with each succeeding five-second interval (fatigue phenomenon). In the pre-operative myelopathy group there was no significant difference between N1 and N2 (freezing phenomenon). The 15-second test is shown to be reliable in the quantitative evaluation of cervical myelopathy. Although it requires a camera and animation files, it can detect small changes in neurological status because of its precise and objective nature

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.

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

Aim. To assess the safety of day case lumbar decompressive surgery. Method. Retrospective study of 233 consecutive patients undergoing DCLDS who were identified from a prospective electronic database. Results. Between Jan 2011 and April 2014, 131 open and 102 microscopic surgeries were done in patients with mean age of 46 (16–88) years and male: female ratio of 136 (59%):97 (41%). Inclusion criteria were no known anesthetic reaction, ASA grade I or II, BMI <35, less than 30 minutes travel time and responsible home carer. Patients were discharged after clinical assessment with cauda equina advice and emergency contact number. 215 (92%) procedures were single level, of which 188(87%) unilateral and 27 (13%) were bilateral procedures. 18 (8%) procedures were multiple levels, of which 12(67%) unilateral and 6 (33%) were bilateral procedures. Majority, 107 (50%), 97 (45%) procedures were done at L5/S1 and L4/L5 levels respectively and rest 11(5%) at higher level. The 7 day and 30 day re-presentation figures were 7 (3%) & 15(6.4%) as following: Pain (n=3), Medication (n=2), Wound issues (n=5), Infection (n=2), Headache (n=2), ?VTE (n=1). Eleven were sent home and 4 (1.7%) were admitted with 2 requiring further surgery, one revision discectomy and one wound washout. No cauda equina or compressive haematoma were encountered. Conclusion. This study demonstrates that open and microscopic lumbar discectomy at single or multiple levels can be performed safely as a day case procedure. The representation rate to the ED can be potentially reduced by better advice and pain management. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

To audit the routine measurement of Vitamin B12 levels prior to cervical decompressive surgery. Retrospective analysis of medical records and pathology results of patients who underwent decompressive cervical surgery for myelopathy over a 6 month period. 26 patients were identified from theatre records. 21 out of 26 patients did not have vitamin B12 levels checked prior to their decompressive surgery. The reports in the literature of co-existent B12 deficient myelopathy and mechanical compression are a cause for concern. Although the incidence of this is unknown and unlikely to be common, good clinical practice would suggest that we should be routinely monitoring B12 levels in myelopathic patients. We have introduced new standards for routinely checking B12 levels pre-operatively and intend to re-audit the effectiveness of these in six months time

Introduction. Changes in the central nervous system (CNS) pathways controlling trunk and leg muscles in patients with low back pain and radiculopathy have been observed and this study investigated whether surgery impacts upon these changes. Methods. Parameters of corticospinal control were examined on 3 occasions in 22 patients prior to, at 6 and 26 weeks following lumbar decompression surgery and in 14 control subjects at the same intervals. Electromyographic activity was recorded from tibialis anterior (TA), soleus (SOL), rectus abdominis (RA), external oblique (EO) and erector spinae (ES) muscles at the T12 & L4 levels in response to transcranial magnetic stimulation of the motor cortex. Results. In the surgical group, asymmetries in the size of motor evoked potentials (MEPs) in TA (P=0.001) and in the cortical silent periods (cSP) were found between the left and right sides in SOL (P=0.005) and ES at L4 (P=0.014) prior to surgery. This was not observed at 6 or 26 weeks. Abdominal responses could be evoked in 12 patients and there was a significant reduction in the cSP contralateral to the pain in EO (P=0.034) and RA (P=0.041) at 6 weeks. These parameters remained stable in controls over time. Discussion. The fact that changes appear to stabilise at 6 weeks is of interest as this parallels clinical outcome studies. Current work is ongoing to examine these excitability changes in both inhibitory and excitatory cortical pathways in these patients, and to what extent they may be related to clinical outcome

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