Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

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). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Aims. The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons. Methods. An organizational model is presented based on case centralization in hub hospitals and early management of surgical cases to reduce hospital stay. Data from all the patients admitted for emergency spinal surgery from the beginning of the outbreak were prospectively collected and compared to data from patients admitted for the same reason in the same time span in the previous year, and treated by the same integrated team. Results. A total of 19 patients (11 males and eight females, with a mean age of 49.9 years (14 to 83)) were admitted either for vertebral fracture or spinal cord compression in a 19-day period, compared to the ten admitted in the previous year. No COVID-19 patients were treated. The mean time between admission and surgery was 1.7 days, significantly lower than 6.8 days the previous year (p < 0.001). Conclusion. The structural organization and the management protocol we describe allowed us to reduce the time to surgery and ultimately hospital stay, thereby maximizing the already stretched medical resources available. We hope that our early experience can be of value to the medical communities that will soon be in the same emergency situation. Cite this article: Bone Joint J 2020;102-B(6):671–676

Background and Purpose. The UK's NIHR and Australia's NHMRC have funded two randomised controlled trials (RCTs) to determine if lumbar fusion surgery (LFS) is more effective than best conservative care (BCC) for adults with persistent, severe low back pain (LBP) attributable to lumbar spine degeneration. We aimed to describe clinicians’ decision-making regarding suitability of patient cases for LFS or BCC and level of equipoise to randomise participants in the RCTs. Methods. Two online cross-sectional surveys distributed via UK and Australian professional networks to clinicians involved in LBP care, collected data on clinical discipline, practice setting and preferred care of five patient cases (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were also asked about willingness to randomise each patient case. Results. Of 174 responses (73 UK, 101 Australia), 70 were orthopaedic surgeons, 34 neurosurgeons, 65 allied health professionals (AHPs), 5 others. Most worked in public health services only (92% UK, 45% Australia), or a mix of public/private (36% Australia). Most respondents chose BCC as their first-choice management option for all five cases (81–93% UK, 83–91% Australia). For LFS, UK surgeons preferred TLIF (36.4%), whereas Australian surgeons preferred ALIF (54%). Willingness to randomise cases ranged from 37–60% (UK mean 50.7%), and 47–55% (Australian mean 51.9%); orthopaedic and neuro-surgeons were more willing than AHPs. Conclusion. Whilst BCC was preferred for all five patient cases, just over half of survey respondents in both the UK and Australia were willing to randomise cases to either LFS or BCC, indicating clinical equipoise (collective uncertainty) needed for RCT recruitment. Conflicts of interest. None. Sources of funding. No specific funding obtained for the surveys. DB, SA, AG and NEF have funding from the National Institute for Health Research (NIHR) UK (FORENSIC-UK NIHR134859); NEF, DB and SA have funding from the Australian National Health and Medical Research Council (NHMRC FORENSIC-Australia GA268233). AG has funding from Orthopaedic Research UK (combined with British Association of Spine Surgeons and British Scoliosis Society) and Innovate UK. NEF is funded through an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (ID: 2018182)

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

To determine if the term “back pain” has uniform meaning to spinal surgeons. A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain. An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting. 67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05). The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral. This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

Competency levels of AOSpine members (Europe) based on whether or not they had undertaken a full 12 month fellowship in spinal surgery. Self-assessment questionnaire distributed to members (60 questions relating to: previous surgical training, fellowships and their nature, and both theoretical and practical competency amongst basic and advanced spinal conditions). 289 completed responses. Competency levels with(out) fellowship; differences in fellowship training; overall competence in spinal surgery as neurosurgeons versus those trained as orthopaedic surgeons. Competency defined as those able to deal with complications or able to perform without supervision. 28% (n=80) undertook a full 12 month fellowship. Notable differences between groups were identified (fellowship vs no fellowship): spinal deformity (58% vs 26%), cervical trauma (83% vs 59%), cervical stabilisation (78% vs 53%), lumbar and thoracic trauma (85% vs 57%) and anterior surgery (66% vs 41%) and its complications (46% vs 23%). Interestingly of the whole group only 43% were competent in the actual practice of conservative management of spinal conditions. There was no significant difference in theoretical knowledge or practical skills between orthopaedics surgeons and neurosurgeons. Fellowship training is effective, but there are deficiencies in areas. In order to provide a routine and emergency service as a spinal surgeon, competency at relatively common procedures must be reached. Our data demonstrates a lack of uniformity in such competencies, and we believe efforts towards a formal curriculum for spinal training should be embarked upon

Cervical spine disorders represent a good proportion of the daily practice of many neurosurgeons. The rapidly increasing knowledge base on spinal conditions and the progressive complexity of surgical interventions appear to be generating a renewed interest in this evolving subspecialty among neurosurgical trainees. In order to assess the current level of spinal surgery training and conveyed competence in dealing with spinal disorders, a self assessment questionnaire was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Society) training courses. 126 questionnaires were returned with a return rate of 32%. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60,3% of total) representing 25 European nations. A separate analysis of the data pertaining to cervical spine disorders revealed 80% of the trainees completing their training in University hospitals with cervical spine injuries predominantly managed by neurosurgeons (75%). In their practical skill assessment, 78% of the senior trainees were competent in the treatment of cervical disc herniation and cervical spinal stenosis in their anterior microsurgical techniques. In emergency management of cervical spinal trauma, 45% of the senior trainees were competent in being able to perform procedures without direct supervision. Regarding skills in anterior and posterior cervical stabilisation techniques, 33% and 15% respectively were competent in performing as well as dealing with complications & difficulties that may arise. Spinal surgery training in European residency programs has clear strength in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation. Deficits are revealed in the management of spinal trauma and spinal conditions requiring the use of implants, with the exception of anterior cervical stabilisation. In order to achieve a high level of competency, EANS trainees advocate the development of a post-residency spine sub-specialty training program

Awake Rapid Heavy-Weight Closed Reduction (ARHWCR) with weights from 18 to 72 kg was used to reduce six unilateral and nine bilateral cervical facet dislocations. Frankel grading ranged from A to E. Reduction was achieved in all 15 patients with no neurological deterioration. Motor ASIA score improved from a prereduction mean of 64 points to 73 after reduction. Before and after reduction, MRI studies were done on all 15 patients. ARHWCR was done irrespective of the MRI findings. The MRI results were evaluated by five orthopaedic surgeons, five neurosurgeons and five radiologists. The radiologists reported 55% disc herniation in four neurologically-intact patients. On pre-reduction MRI, 34% of anterior longitudinal ligaments and 64% of posterior longitudinal ligaments were reported to be disrupted. They were reported intact on post-reduction MRI. These findings indicate that MRI studies may be open to misinterpretation. Viewing the prereduction MRI, the orthopaedic and neurosurgeons opted for surgical decompression and reduction in 53% of cases. Looking at the post-reduction MRI, they felt that reduction was adequate in 80.6% of cases, but on personal judgment believed that surgical decompression might be of benefit in the remaining 19.4%. ARHWCR is an effective, safe and rapid way of relieving cord compression. Prereduction MRI, irrespective of the patient’s neurological status, is not indicated in acute cervical facet dislocations and can lead to unnecessary surgical intervention

Background: General practitioners (GPs), orthopaedic surgeons, neurosurgeons, rheumatologists and pain consultants manage the majority of patients with chronic low back pain (CLBP) in the Republic of Ireland. However, little is known about their attitudes and beliefs and the factors that influenced them. This study aimed to investigate factors that influenced doctors’ attitudes and beliefs to CLBP. Method: A cross-sectional questionnaire was mailed to a random sample of GPs (n=750; 35%), and all orthopaedic surgeons (n=81), neurosurgeons (n=9), rheumatologists (n=26), and pain consultants (n=24) in the republic of Ireland. The questionnaire pack contained a demographic data form, two clinical vignettes, and an attitudes measure, the Pain Attitudes and Beliefs Scale (PABS.PT). Approval was obtained from the UCD Human Research Ethics Committee. Results: The response rate was 58% (n=523). Doctors were qualified 23.4±9.4 years. Analysis of the vignettes showed there was no significant difference (p> 0.05) between those who had undertaken postgraduate education (PGE) regarding referral rates to physiotherapy, investigations, or secondary care. Prescription rates were significantly lower for those who had undertaken PGE (88% v 94%, χ. 2. =4.95, p< 0.05), as was their biomedical score on the PABS.PT (41.3 v 43.1, df=507, p=0.03). The number of years since qualification was dichotomised (1–23 yrs, > 23 yrs), and there was no significant difference in the management of the vignettes, except referral rates for investigations which was greater for doctors qualified > 23 years (3% v 52%, χ. 2. =10.71, p=0.001). Conclusion: Demographic factors (PGE and the number of years since qualification) did not significantly influence doctors’ practice behaviour

Background. Persistent low back and leg pain is a common and highly disabling musculoskeletal condition. Many patients seek the opinion of a neurosurgeon with a view to surgical intervention. Few data are available which document the experiences of patients at these consultations. Aims. To investigate the experiences of patients seeking a neurosurgical opinion for back and leg pain. Methods. 15 patients (Males 9 Females 6) were consented and recruited into this study and participated in an in-depth semi-structured interview about their experiences of the consultation. Interviews were recorded and transcribed. Transcribed data were read independently by two researchers and analysed using grounded theory. Results. Three subgroups of patients were identified from the interviews. Group 1: Patients that were offered surgery and described a positive experience. Group 2: Patients that were not offered surgery and described a positive experience. Group 3: Patients that were not offered surgery and described a negative experience. Analysis revealed a number of different themes pertaining to the experiences of each group. However, two overarching themes of i) meeting patients' expectations and ii) the factor of hope, emerged as significant contributors to their experience and were evident in all three subgroups. Conclusion. Findings identified the need to manage patient expectations in the consultation in order to provide a positive experience. Providing patients with hope who are not undergoing surgery, but who have an expectation for it, is likely to provide a more positive experience and therefore increased satisfaction with care. No conflicts of interest. Part funded by North East London Foundation Trust

Improve the quality of care mine-explosive wounds and preventing infection in mine blast injury. We have treated 19 patients affected by MEI during Anti-Terrorist Operation (ATO) in Ukraine. The patients had been received by our department within 5–28 days after the injury. All patients were comprehensively examined (general surgeon, neurosurgeon, thoracic surgeon, CT, X-ray, ultrasound, lab tests). 14/19 patients had an open fractures (10 of those 14 had a soft tissue defects). All patients with open fractures underwent secondary surgical treatment (radical debridement, irrigation, ultrasonic cavitation, fracture stabilization by external fixation). The patients with soft tissue defects underwent variety of plastic surgery. After soft tissues healing a plate or IM nail was installed. Evaluation of results was based on X-ray monitoring and the lower limb function assessment. 16 patients had full fracture consolidation and good function, 3 patients had slow consolidation and limitation of movement. Analysis of treatment showed that adherence to radical debridement and thorough soft tissue management led to significant reducing of the incidence of infectious complications in combat related fractures

Aims

The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment.

Purposes of the study and background. The care and cure of patients with low back disorders is of a multidisciplinary nature. Cooperation and communication between the disciplines would improve standardized care delivery to the patient. We engaged to establish a national group of multidisciplinary spine specialists to promote research and education in the field of spinal disorders. Summary of the methods used and results. A multidisciplinary group of spine professionals, opinion leaders and research leaders in spinal disorders in the Netherlands were invited to participate in a national network (“Netwerk Wervelkolomaandoeningen”). The group consists of physiotherapists, family physicians, neurosurgeons, orthopedic surgeons, anesthesiologists, as well as clinical researchers and epidemiologists. Group meetings were organized in various locations in the country. Priorities were set and divided in research and education. Communication lines were established with a resource website and a linked-in page. The first educational series of symposia for primary care professionals on multidisciplinary approaches for disc herniation and spinal stenosis is being organized in different regions in the Netherlands. The first meetings on research initiatives are being held on an idea-driven basis. Conclusion. The Dutch Network for Spinal Disorders is a promising initiative that has the potential to align care and cure for spinal disorders across disciplines

Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.