Abstract

Abstract

Background

Loss of muscle mass (sarcopenia) and function in ageing are associated with reduced functional ability, quality of life and reduced life expectancy. In cancer patients, age related muscle loss may be exacerbated by cachexia and poor nutritional intake. Individuals with widespread disseminated disease are most prone to increasing functional decline, increased morbidity and accelerated death. However subjective assessments of physical performance have been shown to be poor indicators of life expectancy in these patients.

Introduction

Microdiscectomies and microdecompressions are traditionally defined as procedures performed with a small incision using magnification. There are no studies in the literature comparing the magnification techniques used in these operations. We compared magnifying loupes and microscopes as the senior author was trained with both instruments and was equally comfortable using both.

Introduction

The main symptoms in multiple myeloma are the result of skeletal destruction mainly the vertebral column. The current treatments for multiple myeloma include radiotherapy and chemotherapy but unfortunately it is still incurable. However, the symptoms and quality of life of these patients can be improved by cement augmentation which has gained popularity in the recent years.

Clinical and radiological assessment of results of vertebral body stenting procedure.

Introduction: Use of metallic stents along with cement have shown good restoration of the vertebral body in cadaveric spines. We have presented the early results of vertebral body stenting done at Royal Derby Hospitals.

Patients and Methods: All patients had a transpedicular approach to the vertebral body. The vertebral body stent was expanded using a balloon as in balloon kyphoplasty. The balloon was removed leaving the stent in place. The resultant cavity was filled with partially cured polymethyl methacrylate in osteoporotic fractures and calcium phosphate cement in traumatic fractures.

Radiological assessment included pre operative measurement of vertebral body angle, correction achieved and maintenance of correction at follow up

All patients were assessed using the visual analogue score and oswestry disability index.

The procedure was done in 14 fractures (10 patients). 9 fractures were traumatic while 5 were osteoporotic fractures. The mean age of the traumatic fractures was 54.28 years while the mean age of osteoporotic fractures was 82.34 years. Mean follow up was 10 months. All traumatic fractures were type A 3.1. Mean vertebral body angle correction achieved was 8.3° (4° to 14.2°). None of the patients lost the reduction at follow up.

The mean VAS for pain at 6 months was 3.8. The mean oswestry disability index was 22% for traumatic fractures, while it was 44% for osteoporotic fractures.

Vertebral body stenting is a safe procedure. It was successful in restoring the anterior column with encouraging radiological and clinical results.

To assess how effective are the prognostic scores and the role of delayed presentation in predicting the outcomes in patients with metastatic spine disease.

Retrospectively data collected from December 2006 to December 2009. Medical records review included types of tumours, duration of symptoms, duration from referral to definitive treatment, expected survival, functional status before and after treatment. Karnofsky performance score and Modified Tokuhashi were used.

Results: 50 patients underwent surgical stabilisation for metastatic spine disease with or with out cord compression. Age ranged from 39 to 87 years (Avg: 64). Patients had four main types of tumours; (Myeloma 30%, Lymphoma 22% Lung CA 16% and Renal 12 %).

Inpatients without cord compression, the average time from referral to definitive treatment is 17 days. Over all fictional status improved in 70% of cases following surgical intervention. Patients who presented with cord compression had surgery with in 49 hours. Patients with high prognostic scores did not survive as long as expected. On the contrary, patients with poor prognostic scores survived longer than expected. This discrepancy is significant in patients with lung and renal malignancies. Patients with Myeloma did well as per the prognostic scores.

Prognostic scores are not uniformly effective in all types of malignancies. Factors like delayed presentation and general condition were not included in the prognostic factors. Hence, we conclude that we cannot make a decision purely based on the prognostic scores to perform either palliative or definitive surgery.

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients.

Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009.

Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort.

All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group.

Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future.

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst.

A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score.

Overall patient satisfaction was recorded on a scale of 0-10.

38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group.

Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications.

We retrospectively reviewed the records of 16 children treated for spondylodiscitis at our hospital between 2000 and 2007. The mean follow-up was 24 months (12 to 38). There was a mean delay in diagnosis in hospital of 25 days in the ten children aged less than 24 months. At presentation only five of the 16 children presented with localising signs and symptoms. Common presenting symptoms were a refusal to walk or sit in nine children, unexplained fever in six, irritability in five, and limping in four. Plain radiography showed changes in only seven children. The ESR was the most useful investigation when following the clinical course of the disease. Positive blood cultures were obtained in seven children with Staphylococcus aureus being isolated in five. Antibiotics were used in 14 children and spinal bracing in six. Children with spondylodiscitis often present with a confusing clinical picture leading to late diagnosis.

The early use of MRI in the investigation of children with an atypical picture may avoid unnecessary delay in starting treatment and possibly prevent long-term problems. All except one of our children had made a complete clinical recovery at final follow-up. However, all six children in the > 24-month age group showed radiological evidence of degenerative changes which might cause problems in the future.

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.

Background: Recent evidence suggests that surgical intervention with radiotherapy is superior to radiotherapy alone. Predicting the life expectancy is critical in decision making whether to go for palliative or definitive surgery.

Aim: To assess the accuracy of Modified Tokuhashi’s score (MTS) in predicting survival in patients with metastatic spinal tumours and cord compression; and to assess the incidence and role of early referral and diagnosis.

Material and Methods: In this retrospective study, we collected two years’ data. Medical record was reviewed for the source of referral, delay in symptom onset to diagnosis and treatment, types of tumours, Karnofsky score to assess patients’ disability, Modified Tokuhashi score to assess the expected survival and final outcome.

Results: 37 patients were included. Age ranged from 39 to 87 years(avg:64, median:66).30%(n=11) patients presented with cord compression and 70%(n=26) with instability pain. Cancer diagnosis had already been established in 57% cases off which 57% were referred from oncology and 43% from haematology. Remaining 43% patients were referred from GPs(68%) and medical specialties in the hospital(32%).51% patients presented early(< 3 months) and 22% presented late(> 6 months). Functional outcome improved in 58% patient following surgical intervention in early referral group(avg MTS:9.45) and improved in 61.5% patients in late referral group(avg MTS:9.5).

In patients with cord compression, average MTS was 6.6. Expected survival was < 3 months in 45.4% and 3–12 months in the remaining patients. 81%(n=9) patients of this group had surgical intervention resulting in satisfactory functional outcome in 36%. 3 patients had surgery done within 24 hours and another 4 within 72 hours(median:58).

In patients without cord compression, average MTS was 10.1. Expected survival was > 12 months in 84%. Surgical intervention was done in 84.6%(n=22) patients. 43% patients had posterior decompression and stabilisation with average MTS of 8.5 and satisfactory outcome in 56% patients. 13.5% patients had 2-stage anterior and posterior stabilisation with average MTS of 11.2 and satisfactory outcome in 100%. Average time from referral to definitive treatment was 17 days(mean:8, mode:8). Overall functional outcome was satisfactory in 84% patients.

30% patients died subsequently due to deterioration of their tumour-related problems with mainly Lung CA(36%) and Lymphoma(36%). Average MTS in these patients was 6.8. 5 patients died within 3 months of surgery.

Conclusion: Modified Tokuhashi score was consistent with patients’ expected survival and functional outcome. There was no major difference in functional outcome in relation to early or late referral. We conclude that Modified Tokuhashi score is helpful to make a decision for intervening surgically.

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

In recent years various surgical morphoplastic techniques have been employed in an attempt to improve on the disappointing natural history of this manifestation of biological failure.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies.

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining Visual Analogue Pain Score (VAS), vertebral height, vertebral and kyphosis angles, Oswestry Disability Index and Hospital Anxiety and Depression Score (HADS).

50 patients in our kyphoplasty group have undergone 91 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.8 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.3 and 2.7 respectively (p< 0.001).

Functional status ODI scoring improved from a pre-operative score of 54 to 47 post-operatively, to 40 at 6 weeks, and further, to 39 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.0, 11.2, 11.1 and 11.7 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle (p< 0.01) with increases in the anterior, middle and posterior vertebral body heights of 19, 31 and 9% respectively (p< 0.001). No significant improvement of kyphosis angle was identified.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.

Very few reports exist regarding use of intra-operative autologenous transfusion in adult spinal fusion surgery. Specific indications for use of cell saver in thoraco-lumbar spinal instrumentation are not clearly determined. Our objective was to identify the clinical factors associated with increased risk of intra-operative blood loss. To analyse the safety and benefits of using cell saver and to determine the cost-effectiveness.

51 consecutive thoraco-lumbar instrumented fusion over 14 months reviewed. There was no randomisation. Cell saver group consisted of 25 patients and control group consisted of 26 cases. Patients with degenerative scoliosis and tumours excluded. Clinical notes were reviewed.

Demographic data were comparable between the two groups. Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group. Levels of fusion ranged from 1–7 (Mean=2.8) in the cell saver group and 1–4 (Mean=1.9) in the control group. Mean duration of surgery was 15 minutes longer in study group. Intra-operative blood loss was higher in cell saver group (mean=1245 mls vs 800 mls). Significant indicators for duration of surgery were number of levels fused (p< 0.0001), patient weight (p=0.003) and revision surgery (p=0.029). Significant indicators for predicting blood loss were number of levels fused (p< 0.001) and duration of surgery (p=0.0304). 20% in study group (8 units of red cells) and 26% in control group (17 units of red cells) required blood transfusion. Percentage drop in the post-operative haematocrit was 19.1 in study group compared to 36.3 in control group.

In conclusion, 44.38% blood salvaged (35–38% in spinal literature). Use of cell saver significantly decreased post-operative need for blood transfusion. Number of levels of fusion, duration greater than 4 hrs and a low pre-op Haemoglobin/Haematocrit were significant parameters in predicting intra-operative blood loss. If blood loss is less than 700 mls, gains from cell saver are debatable.

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.

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.

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.

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. These published case series report the use of several end points, variously including Visual analogue score (VAS), Vertebral height, kyphosis angle and Oswestry disability index (ODI).

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining VAS, vertebral height, vertebral and kyphosis angles, ODI and hospital anxiety and depression score (HADS).

40 patients in our kyphoplasty group have undergone 70 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.9 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.7 and 3.8 respectively.

Functional status ODI scoring improved from a pre-operative score of 53 to 48 post-operatively, to 42 at 6 weeks, and further, to 41 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.3, 12.0, 10.1 and 11.3 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle with increases in the anterior, middle and posterior vertebral body heights of 26, 40 and 11 % respectively. Kyphosis angle has been improved by a mean angle of 2 degrees.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.

Background: Cell Saver technique using intra-operative autologenous transfusion known to conserve homologous blood resources.

Specific indications for use of cell saver in thoracolumbar spinal instrumented fusion not clearly determined.

No previously published literature from Britain to our knowledge.

Objectives: To identify the clinical factors associated with increased risk of intra-operative blood loss.

To analyse the safety and benefits of using cell saver technique.

Method: A total of 51 consecutive spinal instrumented fusion cases during last 14 months reviewed.

There was no randomisation; use of cell saver was at surgeon’s discretion.

Results: Demographic data including age, weight, smoking and prior surgery were similar between the two groups.

Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group.

Conclusion: 44.38% blood salvaged (35–38% in spinal literature).

Use of cell saver significantly decreased the risk of post-operative need for blood transfusion.

Neuromuscular scoliosis is a difficult condition to treat. Curve severity, secondary pelvic obliquity and poor respiratory function can make operative treatment and post operative care challenging. The benefits to the child in terms of improved sitting position and trunk posture can be considerable. We present a large consecutive series of patients with neuromuscular scoliosis treated surgically at our institution.

The aim of this work was to study the clinical and radiographic impact of surgery for neuromuscular scoliosis.

Data was gathered from patient records and radiographs for all cases of neuromuscular scoliosis treated surgically between April 2002 and Feb 2005. 52 cases were identified. They fell into 2 surgical groups: single stage posterior correction and two stage anterior and posterior correction. All posterior instrumentation was transpedicular. Complications, length of stay, and change in severity of sagittal and coronal plane deformity were recorded.

Average pre-operative Cobb angle was 85°. There were 16 patients with additional sagittal plane deformity. Average percentage improvement of Cobb angle was 59%. The correction was better in two stage procedures. Pelvic obliquity was improved in those who were obligatory sitters. Fusion rate was 83% for those followed up more than 1 year. ITU stay was longer in single stage procedures. Complication rate was 58%.

We have shown that with appropriate patient selection the correction of neuromuscular scoliosis can achieve good results with high fusion rates. Two stage correction confers correctional advantage on those who have sufficient respiratory reserve to tolerate it.

We retrospectively reviewed 19 femoral non-unions. Age group ranged from 17–72 yrs with mean of 40 yrs. 12 were men and 7 were women. 11 fractures involved diaphysis and 8 involved supracondylar area. 5 cases were infected non-unions. Time from fracture to defini-tive treatment varied from 5 to 88 months (mean 21 months). Open technique was used in 18 cases. In 8 cases we have used autogenous cancellous bone graft and in 3 cases BMP7 was used in addition to bone graft. 9 cases were treated with Ilizarov frame without bone graft, 6 with plate & bone graft, 3 with intramedullary nail and 1 with bone graft alone. Internal bone transport was carried out in 5 cases to achieve limb length equality. Fracture union was achieved in 16 patients with 7 excellent and 8 good results as per ASAMI criteria. 15 cases achieved excellent to good functional results. Because of persistent infection, 2 distal femoral non-unions required transfemoral amputation. Treatment was discontinued due to psychiatric illness in 1 patient with Ilizarov frame. Two of the patients in Supracondylar group developed knee stiffness. Pin tract infection is a common complication in Ilizarov group.

Adequate reduction & stabilization is key to success. Non-unions without any complications can be treated with exchange nail or open reduction and plating. Ilizarov method is effective for non-unions complicated by distal location, infection and bone loss. Psychological assessment is important before considering Ilizarov method of treatment.

Aim and methods: We present our results on the treatment an outcome of femoral non-unions in our institution as tertiary referral centre. Retrospective analysis was performed using the ASAMI criteria.

Results: 19 patients, 12 men and 7 women were retrospectively assessed. Mean age was 40 years (range 17–72). 11 fractures were in the diaphysiseal area and 8 were in the supracondylar area. 5 cases were infected non-unions. Time from fracture to definitive treatment varied from 5 to 88 months (mean 21 months).

Open technique was used in 18 cases. In 8 cases we have used autogenous cancellous bone graft and in 3 cases BMP7 was used in addition to bone graft. 9 cases were treated with Ilizarov frame without bone graft, 6 with plate and bone graft, 3 with intramedullary nail and 1 with bone graft alone. Internal bone transport was carried out in 5 cases to achieve limb length equality.

Fracture union was achieved in 16 patients with 7 excellent and 8 good results as per ASAMI criteria. 15 cases achieved excellent to good functional results. Because of persistent infection, 2 distal femoral non-unions required transfemoral amputation. Treatment was discontinued due to psychiatric illness in 1 patient with Ilizarov frame. Two of the patients in supracondylar group developed knee stiffness. Pin tract infection is a common complication in Ilizarov group.

Conclusion: Adequate reduction and stabilization is key to success. Non-unions without any complications can be treated with exchange nail or open reduction and plating. Ilizarov method is effective for non-unions complicated by distal location, infection and bone loss. Psychological assessment is important before considering Ilizarov method of treatment.