Aims

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected.

Purpose: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial. Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience. To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs. Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart. All patients reviewed at three months interval in a dedicated epidural follow up clinic and one-year postal and telephonic follow-up. Exhaustive epidural database maintained. VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment, at three months follow-up and one year. Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases. Results: In the largest single series to date, we report on 928 consecutive patients, with three months follow-up and 354 patients with 12 months follow-up. Fifty-eight percent were females, 24% smoked and 4.1% had ongoing litigation due to their pain. The mean age was 56 years with BMI ranging from 17 to 50 (mean=28). Ten (0.6%) patients required subsequent surgical intervention due to disc herniation. The mean VAS, ODI and HADS improved significantly at three months and one-year results were encouraging. Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms achieved facilitating onward referral for physical therapy. Subgroups predicting poor outcome are identified. Positive primary care feedback encourages further recruitment

Summary. Application of RSA in supine and standing positions allows pelvic fracture stability to be measured more accurately than current techniques. RSA may enable a better understanding of these injuries. Introduction. The in vivo stability of the pelvic ring after fracture stabilisation remains unknown. Plain radiographs have a low accuracy in diagnosing loss of fracture reduction over time. Radiostereometric analysis (RSA) is an accurate imaging measurement method that has previously been applied to measure the healing of other fractures. This pilot study investigated the potential application of RSA in supine and standing positions to measure pelvic fracture stability over time and under weightbearing load. Methods. Five patients with a similar type C pelvic ring disruption who were all operated on using the same surgical technique and had RSA markers inserted at the time of surgery. All five patients had a unilateral comminuted sacral fracture lateral to the sacral foramina treated with posterior plating and pubic rami fractures stabilised by external fixation for six weeks. All patients were mobilised partial weight bearing after regaining leg control. RSA examinations at 2, 4, 12, 26 and 52 weeks included three radiographic pairs taken in supine, standing and supine positions at each time point. Two additional RSA examinations were performed the day prior and post pin removal at 6 weeks. Results. All patients ambulated before the 2 week follow-up and progressed uneventfully. At latest follow-up, there were no complications. Minimal displacements (translations less than 0.3mm and rotations less than 0.5°) were recorded between the supine exams pre and post standing at 2 weeks. Hence, the supine examination was found to be a reliable position to measure the migration of the ilium over time. No loss of reduction was identifiable on plain radiographs over time. At 52 weeks, in contrast to plain radiographic results, RSA measurements revealed that one patient had a fracture migration greater than 4mm. Such large displacements could result in sacral nerve root transection, leading to devastating consequences, such as incontinence, for patients whose sacral fractures are through or medial to the sacral foramina. In one patient, the migration recorded for the apparent uninjured posterior complex side exceeded the migration of the injured side suggesting an unrecognised bilateral injury. Comparative RSA examinations pre and post external fixator removal demonstrated that in three patients the injured hemipelvis migrated greater than 2mm after the removal of the external fixator, which may be indicative that the fixator was removed prematurely. Discussion and Conclusion. The application of RSA allows accurate measurement of pelvic fracture stability which is difficult, if not impossible, to identify and quantify with any other imaging techniques. Hence, RSA has the capacity to enable a better understanding of pelvic ring injuries and optimise their treatment

Background: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial. Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience. Objectives: To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs. Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases to measure pain relief, physical and psychological function. Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart. A standard mixture of 80 mgs of triamcinalone plus 7 mls of 1% lignocaine plus 5 mls of 0.9% saline used for all patients. All patients reviewed at 3 months interval in a dedicated epidural follow up clinic. The epidural database included age, BMI, duration of symptoms, smoking, employment status and source of referral, any pending litigation, i.e., work or accident related, MRI results, diagnosis and complications. VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment and at three months follow up. Overall patient satisfaction was recorded on a scale of 0–10 and complications noted. Results: In the largest single series to date, we report on 628 consecutive patients, with 3 months follow up. 58 % were females, 24% smoked and 4.1% had ongoing litigation due to their pain. The mean age was 56yrs with BMI ranging from 17 to 50 (mean=28). 7 (1%) patients required subsequent surgical intervention due to disc herniation. BMI did not affect the outcome. Mean VAS for axial pain reduced from 5.859 to 2.59 at three months. Mean VAS for limb pain similarily reduced from 6.23 to 2.53. Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. Following treatment, overall Patient satisfaction ranged from 0–10 with mean of 5.4. Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms was achieved facilitating onward referral for physical therapy, which is fundamental in optimising outcomes. Long term follow-up is underway. Subgroups predicting poor outcome are identified. Positive primary care feedback encourages further recruitment

Aims

To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs).

The February 2015 Spine Roundup³⁶⁰ looks at: Paracetamol use for lower back pain; En-bloc resection of vertebra reported for the first time; Spinopelvic disassociation under the spotlight; Hope for back pain; Disc replacement and ACDF equivalent in randomised study; Interspinous process devices ineffective

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°.

The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigation-assisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was <  1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48).

Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients.

Cite this article: Bone Joint J 2013;95-B:1417–24.

We describe a case of lumbosacral plexopathy caused by an isolated aneurysm of the common iliac artery. The patient presented with worsening low back pain, progressive numbness and weakness of the right leg in the L2-L4 distribution. This had previously been diagnosed as sciatica. A CT scan showed an aneurysm of the right common iliac artery which measured 8 cm in diameter. Despite being listed for emergency endovascular stenting, the aneurysm ruptured and the patient died.

It is important to distinguish a lumbosacral plexopathy from sciatica and to bear in mind its treatable causes which include aneurysms of the common and internal iliac arteries.