To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year.Purpose:
Methods:
The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined. 68 patients underwent NRB by an ESP (Extended Scope Physiotherapist). 37 females, 31 males, mean age 75 years (range 23–87). Their stenosis was categorized as either lateral recess (n=43), foraminal (n=18), or combined (n=7) on MRI scan evaluation by 2 reviewers. Roland Morris Disability Questionnaire and Visual Analogue Scores were recorded pre-injection and 6 weeks post injection. 2 year final outcome was recorded with an ‘in-house’ questionnaire. 2 year outcome: Lateral recess stenosis: 37% had surgery, 40% required no further treatment. In foraminal stenosis: 17% had surgery, 50% required no further treatment. Combined pathology: 43% had surgery, 57% required no further treatment. Patients requiring no further treatment rated their 2 year outcome as satisfactory symptom control. Of the whole group 15% required a repeat injection, 7% were referred to pain clinic and one patient had died.Purpose of study and background
Methods and results
The objective of this study was to assess the reliability and appropriateness of statistical shape modelling for capturing variation in thoracic vertebral anatomy for future use in assessing scoliotic vertebral morphology. Magnetic resonance (MR) images of the thoracic vertebrae were acquired from 20 healthy adults (12 female, 8 male) using a 1.5 T MR scanner (Intera, Philips). A T1 weighted spin-echo sequence (repetition time = 294 ms, echo time = 8 ms, number of signal averages = 3) was used. A set of slices (number = 27, thickness = 1.9 mm, gap = 1.63 mm, pixel size = 0.5 mm) were acquired for each vertebrae, parallel to the mid-transverse plane of the vertebral body. Repeated imaging, including participant repositioning, was performed for T4, T8 and T12 to assess reliability. Landmark points were placed on the images to define anatomical features consisting of the vertebral body and foramen, pedicles, transverse and spinous processes, inferior and superior facets. A statistical shape model was created using software tools developed in MATLAB (R2013a, The MathWorks Inc.). The model was used to determine the mean vertebral shape and ‘modes of variation’ describing patterns in vertebral shape. Analysis of variance was used to test for differences between vertebral levels and subjects and reliability was assessed by determining the within-subject standard deviation from the repeated measurements. The first three modes of variation, shown below (green = mean, red and blue = ±2 standard deviations about the mean), accounted for 70% of the variation in thoracic vertebral shape (Mode 1 = 44%, Mode 2 = 19%, Mode 3 = 4%). Visual inspection indicated that these modes described variation in anatomical features such as the aspect ratio of the vertebral bodies, width and orientation of the pedicles, and position and orientation of the processes and facet points. Variation in shape along the thoracic spine, characterised by these modes of variation, was consistent with that reported in the literature. Significant differences (p< 0.05) between vertebral levels and between some subjects were found. The reliability of the method was good with low relative error (Mode 1 = 5%, Mode 2 = 8%, Mode 3 = 19%). Statistical shape modelling provides a reliable method for characterizing many anatomical features of the thoracic vertebrae in a compact number of variables. This is useful for robustly assessing morphological differences between scoliotic and non-scoliotic vertebrae and in assessing entry points and trajectories for pedicle screws.
To review systematically review literature on the early diagnosis of spinal metastases and prediction of spinal cord compression (SCC) due to spinal metastases From 13 electronic bibliographic databases were searched we identified 2,425 potentially relevant articles of which 31 met the inclusion criteria. These were quality appraised. Seventeen studies reported retrospective data, 10 were prospective studies, and three were other study designs. There was one systematic review. There were no randomised controlled trials. There were approximately 7,900 participants in the included studies and 5,782 participants were analysed. The sample sizes ranged from 41 to 859. Cancers reported were: lung alone (n=3); prostate alone (n=6); breast alone (n=7); mixed cancers (n=13); and unclear (n=1). Ninety-three prognostic factors were identified as potentially significant in predicting risk of SCC or collapse. Many of the included studies provided limited information about patient population and selection criteria and they varied in methodological quality, rigour and transparency. Several studies with mixed case populations identified type of cancer (e.g. breast, lung or prostate cancer) as a significant factor in predicting SCC, but determining the risk differential is difficult because of residual bias in studies. Overall the quality of the research was poor. The only predictors identified for SCC were number of spinal metastases, duration of disease, total disease burden and immediate symptomatology of cord involvement.Study Purpose
Methods and results
To take a snapshot opinion of General Practitioner understanding of the prevalence, diagnosis and management of coccydynia. We designed a simple 5 question survey to administer to our local GPs. The survey was sent to 107 GP practices in Devon whose details were provided by The Devon Access Referral Team. We received 128 electronic replies. We also submitted the survey to 50 GPs who attended a study day at our institution – and ensured they had not already completed the electronic format of the same work. Thus we received 178 replies which we believe to be a highly representative sample of our local GPs opinion.Purpose of the study
Methodology
Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America Clear Management Plan Mobilisation Schedule We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management.
Peninsula Spinal Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK. A retrospective audit in 2000 of cases presenting with metastatic cord compression (MSCC) was conducted. In June 2009 we introduced the role of MSCC coordinator. We present the preliminary results from a 6 month comparative audit and discuss whether implementation of the NICE Guidelines have improved the care pathway. Prospective cohort study with retrospective controlled group. Adults with suspected MSCC Length of time to MR imaging % referred for surgical opinion Length of time on bed rest. % undergoing surgery Retrospective audit 2000 38 cases confirmed MSCC. 11 did not have MRI and were treated on the basis of clinical symptoms. Average time from admission to MRI 42 hours. 8 patients (21%) referred for surgical opinion. None had surgery 38 had radiotherapy. Spinal stability documented on 1 patient. 5.5 days average bed rest Prospective audit 2009 54 patients referred to co-ordinator as suspected MSCC. 52 had MRI and 2 had CT. Average time from referral to MRI 41 hours. Average time for patients with neurological deficit 7.6 hours. 54 patients (100%) referred for surgical opinion. 12 patients had surgery (22%). 100% patients had spinal stability documented. Average length of time on bed rest 2 days. It is uncertain whether these results are attributed to the introduction of the NICE guidelines or improved awareness of condition. However we feel that NICE guidelines have improved the care pathway of patients with MSCC. Statement of ethics and interests: Study was approved and registered with audit department.
Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.
