Neurological complications in oncological and degenerative spine surgery represent one of the most feared risks of these procedures. Multimodal intraoperative neurophysiological monitoring (IONM) mainly uses methods to detect changes in the patient's neurological status in a timely manner, thus allowing actions that can reverse neurological deficits before they become irreversible. The utopian goal of spinal surgery is the absence of neurological complications while the realistic goal is to optimize the responses to changes in neuromonitoring such that permanent deficits occur less frequently as possible. In 2014, an algorithm was proposed in response to changes in neuromonitoring for deformity corrections in spinal surgery. There are several studies that confirm the positive impact that a checklist has on care. The proposed checklist has been specifically designed for interventions on stable columns which is significantly different from oncological and degenerative surgery. The goal of this project is to provide a checklist for oncological and degenerative spine surgery to improve the quality of care and minimize the risk of neurological deficit through the optimization of clinical decision-making during periods of intraoperative stress or uncertainty. After a literature review on risk factors and recommendations for responding to IONM changes, 3 surveys were administered to 8 surgeons with experience in oncological and degenerative spine surgery from 5 hospitals in Italy. In addition, anesthesiologists, intraoperative neuro-monitoring teams, operating room nurses participated. The members participated in the optimization and final drafting of the checklist. The authors reassessed and modified the checklist during 3 meetings over 9 months, including a clinical validation period using a modified Delphi process. A checklist containing 28 items to be considered in responding to the changes of the IONM was created. The checklist was submitted for inclusion in the new recommendations of the Italian Society of Clinical Neurophysiology (SINC) for intraoperative neurophysiological monitoring. The final checklist represents the consensus of a group of experienced spine surgeons. The checklist includes the most important and high-performance items to consider when responding to IONM changes in patients with an unstable spine. The implementation of this checklist has the potential to improve surgical outcomes and patient safety in the field of spinal surgery

Primary bone tumors are rare, complex and highly heterogeneous. Its diagnostic and treatment are a challenge for the multidisciplinary team. Developments on tumor biomarkers, immunohistochemistry, histology, molecular, bioinformatics, and genetics are fundamental for an early diagnosis and identification of prognostic factors. The personalized medicine allows an effective patient tailored treatment. The bone biopsy is essential for diagnosis. Treatment may include systemic therapy and local therapy. Frequently, a limb salvage surgery includes wide resection and reconstruction with endoprosthesis, biological or composites. The risk for local recurrence and distant metastases depends on the primary tumor and treatment response. Cancer patients are living longer and bone metastases are increasing. Bone is the third most frequently location for distant lesions. Bone metastases are associated to pain, pathological fractures, functional impairment, and neurological deficits. It impacts survival and patient quality of life. The treatment of metastatic disease is a challenge due to its complexity and heterogeneity, vascularization, reduced size and limited access. It requires a multidisciplinary treatment and depending on different factors it is palliative or curative-like treatment. For multiple bone metastases it is important to relief pain and increases function in order to provide the best quality of life and expect to prolong survival. Advances in nanotechnology, bioinformatics, and genomics, will increase biomarkers for early detection, prognosis, and targeted treatment effectiveness. We are taking the leap forward in precision medicine and personalized care

Summary. Neurological deficits resulting from spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy. Introduction. Nasopharyngeal carcinoma has been reported to have a higher incidence of distant metastases to the spine. This study was conducted to evaluate the incidence, presentation and management of neurological involvement related to spinal metastasis from nasopharyngeal carcinoma. Patients and Methods. 814 patients with the diagnosis of NPC who presented to the National University Hospital (NUH), Singapore, over a 5-year period (2007–2011) were recruited for this study. Case records from clinics, wards, operating theatres at NUH and nationwide electronic records of polyclinics and Emergency Medical Department (EMD) were obtained and reviewed. The data collected included demographics, medical history, radiologic and histopathology reports. Results. Of 814 patients with NPC, 99 had spinal metastasis. 26 were treated with radiotherapy, 25 with chemotherapy, 5 with both chemo and radiotherapy and 6 with surgery. Out of 6 patients requiring spinal surgical procedure, 3 had neurological deficits in the form of focal sensory or motor deficits and 4 had symptoms of pathologic fracture. One patient had both neurological deficit and pathological fracture. All these 6 patients were treated with a spinal surgical procedure of stabilization and/or decompression. Discussion/Conclusion. Spinal metastasis is common in patients with NPC and back pain is the usual presentation. Neurological deficits resulting from nerve root or spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy

Introduction and Objective. Postoperative pain control in shoulder surgery is challenging even in arthroscopic procedures. Acute postoperative pain can last up to 48hrs despite using multimodal analgesia. Different techniques have been used to control acute pain following shoulder surgery. The most common technique currently used in shoulder surgery at the elective orthopaedic centre in Leeds is a combination of general anaesthetic (GA) and interscalene block (ISB). ISB maybe very effective, however, carries many risks and potential side effects such as brachial plexus injury and paralysis of the vagus and laryngeal recurrent nerves as well as cervical sympathetic nerve and pneumothorax. ISB can also be associated with higher incidence of neurological deficit compared to other peripheral nerve blocks; up to 14% at 10 days in some cases. As such we decided to examine the use of ISB for achieving pain control in our elective unit. Materials and Methods. A prospective consecutive series of 217 patients undergoing shoulder surgery were studied. These were grouped into 10 groups. All procedures were arthroscopic apart from shoulder arthroplasty procedures such as hemiarthroplasty and total shoulder replacements (TSRs). The choice of regional anaesthesia was ISB with GA as standard practice. Visual analogue scores (VAS) at 0hrs, 1hr, 2hrs, 4hrs and 6hrs; and total opiates intake were recorded. A one-way single factor ANOVA was used as preferred statistical analytical method to determine whether there is a difference in VAS scores and total opiates intake amongst the groups. Postoperative analgesics were used for pain relief, although these were not standardised. Results. In total shoulder replacement group, although the RSR group used more morphine on average compared to the ASR group (Mean morphine intake 6.5mg vs 3mg), this was not statistically significant (F<Fcrit; p value= 0.19). When comparing all the arthroplasty groups, the difference in mean morphine intake was also statistically not significant (F<Fcrit; p value=0.24). However, when comparing all 10 groups’ morphine intake there was a statistically significant difference amongst these groups (F>F crit; p value=0.03). Interestingly, there was a statistically significant difference in VAS at 0hrs (F>Fcrit p value=0.01); 1hrs (F>Fcrit; p value=0.00), and at 6hrs (F>Fcrit; p value=0.02) when comparing all 10 groups. Conclusions. ISB is an effective technique in achieving pain control in shoulder surgery; however, there are still variations in analgesic needs amongst groups and the use of alternative techniques should be thus explored. A future prospective study looking at acute pain for a longer period of time after shoulder surgery would explore the effectiveness of ISB in achieving pain control consistent with rehabilitation requirements

Introduction. Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications. Methods. Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were offered postoperative slab/cast and this was continued for six weeks. The remaining 22 patients were not offered any plaster. All patients were followed-up for two years. Results. The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p = 0.02). Also, significantly lower heel widening was reported in the plaster group (p = 0.03). Although, there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusion. Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures

Objective. Lumbar spinal stenosis (LSS) is a common spinal disorder mostly caused by the arthritic process. In cases with refractory complaints or significant neurologic deficit, decompressive surgery with or without instrumented fusion may be indicated. We aimed to investigate the surgical outcome of multi-level LSS in the patient with stable spine treated by simple decompression versus decompression and instrumented fusion. Methods: We retrospectively studied 51 patients (25 male, 26 female) with stable multi-level (>2 levels) LSS who were treated by decompressive surgery alone (group A, 31 cases) and decompression and instrumented fusion (group B, 20 cases) and followed them for more than two years. The patients’ disability and pain were assessed with Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS), respectively. At the last follow-up visit, patient satisfaction with surgery was also scored. Results: The two groups were homogeneous in terms of age, sex, severity of disability and pain. Surgery could significantly improve pain and disability in both groups. Preoperative ODI in group A and B were 51.0±23.7 and 54.5±22.9, respectively, however at the last follow-up visit these parameters improved to 23.1±21.1 and 36.6±21.4 showing a statistical significance. Mean patient satisfaction with surgical intervention was also higher in the simple decompression group, but this difference was not significant. Conclusion: In surgical treatment of the patients with multi-level but stable LSS, simple decompression versus decompression and instrumented fusion could achieve more disability improvement for more than two years of follow-up

There is an inherent risk of iatrogenic new neurological deficit (NND) arising at the spinal cord, cauda equina and nerve root during spinal surgery. Intraoperative neurophysiological monitoring (IONM) can be employed to preserve spinal cord function during spinal surgery. IONM techniques include somatosensory and motor evoked potentials, amongst others. A Canadian survey of 95 spinal surgeons showed that 62.1% used IONM and a similar survey in France of 117 spinal surgeons showed that only 36% used IONM. Unavailability was a common reason for its disuse. Current literature by the British Society of Clinical Neurophysiology has outlined the importance of IONM in preventing NND and the need for the implementation of guidelines for IONM. The lack of an established guideline has resulted in a varied approach in the use of IONM in England. There has been no previous attempt to ascertain the current use of IONM in England. Our study is aimed at assessing the variability of the use of IONM in England as well as identifying the rationale amongst surgeons that dictate their use of IONM. We are in the process of investigating the indications of use of IONM for cervical and lumbar spine procedures in 252 spinal surgeons from 33 hospitals with spinal services. Our survey will illustrate the current use of IONM in spinal surgery in England. It will highlight some of the reasons for the variability of use of IONM and identify factors that can contribute to a more standardised use of IONM in spinal surgery

Spinal infections are rare diseases, whose management highlights the importance of a multidisciplinary approach. Although treatment is based on antibiotics, always selected on coltural and antibiogram tests, surgery is required in case of development of spinal instability or deformity, progressive neurological deficits, drainage of abscesses, or failure of medical treatment. The first step of the algorithm is diagnosis, that is established on MRI with contrast, PET/CT scan, blood tests (CRP and ESR) and CT-guided needle biopsy. Evaluation of response to the specific antibiotic therapy is based on variations in Maximum Standardized Uptake Value (SUVmax) after 2 to 4 weeks of treatment. In selected cases, early minimally invasive surgery was proposed to provide immediate stability and avoid bed-rest. From 1997 to 2014, 182 patients affected by spinal infections have been treated at the same Institution (Istituto Ortopedico Rizzoli – Bologna, Italy) according to the proposed algorithm. Mean age was 56 years (range 1 – 88). Male to female ratio was 1.46. Minimum follow-up was 1 year. Infections were mostly located in the lumbar spine (57%) followed by thoracic (37%) and cervical spine (6%). Conservative treatment based on antibiotics needed surgery (open and/or percuteneous minimally invasive) as an adjuvant in 83 patients out of 182 (46%). Management of spinal infections still remains a challenge in spinal surgery and a multisciplinary approach is mandatory. This algorithm represents the shared decision- making process from diagnosis to the most appropriate treatment and it led to successful outcomes with a low-complication rate. We present this algorithm developed to organize the various professionals involved (orthopaedic surgeons, nuclear medicine and infective disease specialists, interventional radiologists and anaestesiologists) and set a shared pathway of decision making in order to uniform the management of this complex disease

Photodynamic therapy (PDT) uses the strong cytotoxicity of singlet oxygen and hyperthermia produced by irradiating excitation light on a photosensitizer. The phototoxic effects of indocyanine green (ICG) and near-infrared light (NIR) have been studied in different types of cancer cells. Plasma proteins bind strongly to ICG, followed by rapid clearance by the liver, resulting in no tumor-selective accumulation after systemic administration. Kimura et al. have proposed using a novel nanoparticle labeled with ICG (ICG-lactosome) that has tumor selective accumulation owing to enhanced permeability and retention (EPR) effect. In this study, we investigated the efficacy of PDT using ICG-lactosome and NIR for a bone metastatic mouse model of breast cancer. Cells from the human breast cancer cell line, MDA-MB-231 were injected into the right tibia of 26 anesthetized BALB/C nu/nu mice at a concentration. The mice were then randomly divided into three groups: the PDT group (n = 9), the laser (laser irradiation only) group (n = 9), and the control group (n = 8). PDT was performed thrice (7, 21, 35 days after cell inoculation) following ICG-lactosome administration via the tail vein 24 hours before irradiation. The mice were percutaneously irradiated with an 810-nm medical diode laser for 10 min. In the laser group, mice were irradiated following saline administration 24 hours before irradiation. Radiographic analysis was performed for 49 days after cell inoculation. The area of osteolytic lesion was quantified. The right hind legs of 3 mice were amputated 24 hours after the third treatment. Histological analysis was performed using hematoxylin-eosin staining and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining of sagittal sections. The data was analyzed using Tukey-Kramer post-hoc test. P-value of <0.05 was considered significant. X-ray on day 49 of the three groups are considered. The area of osteolytic lesion in the PDT group (7.9 ± 1.2 mm. 2. : mean ± SD) was significantly smaller than that of the control (11.4 ± 1.4 mm. 2. ) and laser (11.9 ± 1.2 mm. 2. ) groups. In histological findings, we observed many TUNEL-positive cells in the metastatic tissue 24 hours after PDT. In the control and laser groups, TUNEL-positive cells were occasionally observed. We have previously reported the effect of ICG-lactosome-enhanced PDT on the cytotoxicity of human breast cancer cells in vitroand on the delay of paralysis in a rat spinal metastasis model. In this study, we demonstrated the inhibitory effect of ICG-lactosome-enhanced PDT on bone destruction caused by human breast cancer cells in vivo. This PDT induced apoptosis and necrosis in the tumor cells. Intralesional resection is often performed for spinal metastases in an emergency. The residual tumor may regrow and cause neurological deficits. We believe that ICG-lactosome-enhanced PDT can decrease the rate of local recurrence through reduction of the residual tumor. PDT with ICG-lactosome and NIR had an inhibitory effect on the growth of bone metastasis of a human breast cancer

Summary Statement. Novel radiopaque UHMWPE sublaminar cables may be a promising alternative to gliding pedicle screws or titanium sublaminar cables within a growth-guidance system for the surgical treatment of early onset scoliosis. Introduction. Growth-guidance or self-lengthening rod systems are an alternative to subcutaneous growing rods and the vertical expandable prosthetic titanium rib for the treatment of early onset scoliosis. Their main perceived advantage over growing rods is the marked decrease in subsequent operative procedures. The Shilla growth-guidance system and a modern Luque trolley are examples of such systems; both depend on gliding pedicle screws and/or sliding titanium sublaminar wires. However, the unknown consequences of metal-on-metal wear debris are reason for concern especially in young patients. In this study, instrumentation stability, residual growth in the operated segment after surgery and biocompatibility of the novel radiopaque UHMWPE cables as an alternative to gliding pedicles screws or titanium sublaminar wires were assessed in an immature sheep model. Materials and methods. Twelve immature sheep were treated with segmental sublaminar spinal instrumentation: dual CoCr rods were held in place by pedicle screws at the most caudal instrumented level (L5) and novel radiopaque UHMWPE (Bi. 2. O. 3. additive) woven cables were placed at 5 thoracolumbar levels. Lateral radiographs were taken at 4-week intervals to evaluate growth of the instrumented segment. Four age-matched, unoperated animals served as radiographic control. After 24 weeks follow-up, the animals were sacrificed and the spines were harvested for histological evaluation and CT analysis. Results. No neurological deficits and no complications occurred during the initial postoperative period. One animal died during follow-up due to unknown cause. At sacrifice, none of the cables had loosened and the instrumentation remained stable. Substantial growth occurred in the instrumented segment (L5-T13) in the intervention group. No significant difference in growth of the operated segment was found between the intervention and control groups. Histological analysis showed fibrous encapsulation of the novel radiopaque UHMWPE sublaminar cable in the epidural space, with no evidence of chronic inflammation. Discussion. Novel radiopaque UHMWPE cables may be a promising alternative to gliding pedicle screws or titanium sublaminar cables within a growth-guidance system. UHMWPE cables may improve growth results due to the smooth surface properties of the UHMWPE cable and address concerns regarding the consequences of metal-on-metal wear debris

Summary Statement. Burst fractures were simulated in vitro on human cadaveric spine segments. Displacement of the facet joints and pedicles were measured throughout the fracture process showing how these bony structures behave when an impact load is delivered. Introduction. Burst fractures account for almost 30% of all spinal injuries, which may result in severe neurological deficit, spinal instability and hence life impairment. 1. The onset of the fracture is usually traumatic, caused by a high-energy impact loading. Comminution of the endplates and vertebral body, retropulsion of fragments within the canal and increase of the intrapedicular distance are typical indicators of the injury. Experimental and numerical studies have reported strain concentration at the base of the pedicles, suggesting that the posterior processes play a fundamental role in the fracture initiation. 2,3. However, little is known about the dynamic behaviour of the vertebra undergoing an impact load. The aim of this study was to provide an in vitro cadaveric investigation on burst fracture, focusing on the widening of the facet joints and pedicles during the fracture development. Methods. Eight three-adjacent-vertebrae segments (T9-T10-T11, T12-L1-L2, L3-L4-L5) were harvested from three human spines preserving the ligaments and intervertebral discs. A testing frame was designed to hold the sample whilst undergoing an axial impact load (delivered through a drop-weight rig). Lateral displacement was recorded by two transducers (LVDT) sampled at 5000 Hz and data were used to calculate the percent maximum dynamic widening (MW) and percent residual widening after the impact (RW). LVDTs were positioned in contact with the most lateral region of the cranial facet joints where the central vertebra was lumbar; or posteriorly to the base of the pedicles for thoracic. Samples were divided into two groups to achieve two different grade of severity of the fracture by delivering two different amount of energy: High (HE) and Low (LE). Samples underwent HR-pQCT scanning prior and after fracturing to assess percent canal narrowing (CN), intrapedicular distance and grade the fracture. Differences between results were assessed using Mann-Whitney U test. Results. Burst fractures were induced in all the samples (fragment retropulsion was present in all HE samples). The median energy delivered to each group was 206J (HE) and 148J (LE) which led to a significant difference in the median CN (HE: 32.4%; LE: 11.8%; p=0.029). No significant difference was found between HE and LE in terms of MW (p=0.11), or RW (p=0.85). Furthermore, MW and CN were poorly correlated (R. 2. =0.13). In all the cases, the first peak in the widening data coincided with MW (median 12.8%, range 4.3–21.8%). RW measurements (median 2.8%, range −1.3–11.5%) were validated against HR-pQCT scans showing excellent agreement (R. 2. =0.93). Discussion/Conclusion. Results from this study provided further insight on the burst fracture process supporting the wedging effect of the adjacent facet joints when the impact load is transmitted. Indeed, the pedicles were forced to widen up to a critical value (MW), after which they fractured. Further experiments will help clarifying the influence of the amount of energy delivered

Summary. Cognitive testing scores do not correlate with physical braking performance. Psychological questioning shows patients are more dependent on driving than a control group. Introduction. Returning to driving after surgery is a multifaceted issue. There are the medical aspects to consider- whether the patient is medically fit to drive. The term ‘medically fit to drive’ can encompass a range of issues which fall to doctors to solve, including the psychological and mental wellbeing. Groups whose governance involves patients or driving do not issue sound advice for patients or doctors to follow. Investigation of aspects affecting a driver's ability to control their vehicle in a safe manner could go towards providing an evidence base for guidance to be issued in the future. Methods. A custom force assessment rig was used to gather peak force and reaction time measurements from a group of patients waiting for, or having undergone lower limb surgery. A bespoke questionnaire that investigated patient's attitudes towards returning to driving; their behaviours and concerns was issued. Other mobility questions were also issued to these patients, including the lower extremity functional scale (LEFS). The final tests (Stroop task, tower of Hanoi, and the opposite worlds test [OWT]) were aimed at assessing a patient's neurological function, in an attempt to investigate the effect of post-operative cognitive dysfunction (POCD) on driving ability. These data were compared against a control cohort. Results. No significant differences were observed in the physical results between cohorts. However, significant differences between the control cohort and patient cohort were observed in a number of tests. The tower of Hanoi was the only significantly different neurological test (p=0.027). The Stroop task and OWT were not significantly different (p=0.103, p=0.131 respectively). There were significant differences in many of the psychological and mobility questions posed (reliance on driving [p<0.001], keenness to return [p=0.014], anxiety about being unable to drive [p=0.019], depression at being unable to drive [p=0.011], worries that driving would cause them pain [p<0.001], and confidence in using public transport [p=0.002]). Activity rankings also had a significant difference, with driving becoming a higher priority in the patient group (p=0.002). There were no significant differences between cohorts in physical testing, but LEFS was significantly different (p<0.001). There was no significant correlation between physical testing and neurological function, so we cannot prove nor disprove that neurological deficits affect physical function. Psychological variables and physical function did not correlate, but LEFS was correlated to a number of psychological variables. Conclusions. Due to the insignificance of correlations between neurological function tests and physical function, further work is recommended to conclusively determine whether there is a link or not. Different and/or additional neurological test batteries should be also considered, for example the CANTAB. Future studies should stratify cohorts based on surgical indication. Extension of the psychological research could identify the most popular goals or activities for those returning from surgery, potentially creating targets for the rehabilitation process