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.

Aims

The aim of this study was to determine whether the sequential application of povidone iodine-alcohol (PVI) followed by chlorhexidine gluconate-alcohol (CHG) would reduce surgical wound contamination to a greater extent than PVI applied twice in patients undergoing spinal surgery.

Introduction

Traditionally complex spinal surgery in Belfast has been performed at the Royal Victoria Hospital (RVH). Since an amalgamation the RVH has become effectively the level 1 trauma centre for the province. The ever increasing complexity of spinal surgery in addition to changes in practice such as the management of metastatic spinal cord, are placing significant demands on the service. At a time when resources are scarce trends in patient profiles are highly important to allow adequate planning of our service.

Background

The incidence of scoliosis is 2/1000 population in the UK with 80% being idiopathic. In the Royal Victoria Hospital, Belfast there are approximately 25 scoliosis operations per year, the majority are for idiopathic causes and are limited to posterior instrumentation and fusion. It is current practice in this hospital to use a cell salvage machine for every case managed by nursing staff.

To determine factors such as age, sex and curve severity in patients with idiopathic scoliosis presenting for the first time to a spine deformity clinic.

A prospective study at a regional spine clinic.

Patients with idiopathic scoliosis presenting for the first time to the scoliosis clinic were entered into a database recording information such as age, symptoms, severity of scoliosis as measured by the Cobb angle (CA), spine rotation measured by Scoliometer, geographical region, person detecting the curve, neurological findings etc. The study period was from June 2008 to September 2009 inclusive.

Fifty consecutive patients with all required information in the database were included in the analysis. All eligible patients were not entered due to logistical reasons.

13 males and 37 females, average age 13.96 (range 1 to 23). 68% were unhappy with the shape of their back, 48% presented with significant pain and 32% had both. The mother first saw the scoliosis in 52%, the rest were seen by either the patient, friends or doctors.

36 were single curves with a mean CA of 34 degrees ranging from 10 to 80 degrees. 52% of patients presented with a curve of 40 degrees or more. 14 had double curves. None of the patients were found to have any abnormal neurological findings.

There are few epidemiological studies in the recent literature. This data was not previously available in our region and initial presentation with a severe curve is a worrying trend which triggered this study.

To analyse the pain distribution in the acute and chronic phase following thoracolumbar fractures.

Prospective observational study

39 patients with fractures between T11 and L2, with no neurological deficit, were treated conservatively. Strict inclusion and exclusion criteria were applied. All had X-rays and MR imaging (whole spine) at post-injury and one-year follow-up.

The patients documented their pain distribution using pain drawing, along with 10 other domains of pain and functional outcomes for a period over 12 months. The pain distribution was analysed. The association of distal pain distribution to - other associated injury, resultant kyphosis, Pre-existing or increase in disc degeneration at the lower non-injured disc levels – were analysed and reviewed

The most common site of the pain distribution in both the acute (90%) and chronic phase (97%) was distal to the fracture (regions - iliac crest, lumbosacral junction and buttock). Factors mentioned above that could be related to distal pain distribution did not show any significant correlation (P>0.5) with different domains of pain outcome.

Some of the commonly believed reasons for distal pain distribution like resultant kyphosis and associated disc/facet pathologies were not supported by our study findings. The distal pain distribution corresponds to the scelerotomal referred pain mapping, which could be the probable explanation. Thoracolumbar pathologies could be the source of pain in patients complaining of low back symptoms. Distal pain distribution of spine pathologies should not be attributed as functional.

Stable thoracolumbar fracture is a common injury. The factors that determine its outcome are unclear. Aspects of injury severity were analysed for their ability to predict outcome by controlling other outcome-affecting factors (patient's pre-injury health status, legal aspects, associated injuries, etc.). No reliable disc injury severity grading system was available and therefore a new system was developed.

A prospective observational study of 44 conservatively treated patients with stable fractures between T11 and L5 was conducted. Bony injury severity was scored based on comminution, apposition and kyphosis parameters. Disc injury severity was scored by the new scale based on variables – Herniation, Indentation, Height decrease and Signal change – seen in MRI. Ten outcome domains (five domains of pain and function each) were assessed at 1 to 2 years from injury. The data was analysed by non-parametric correlation and stepwise-linear regression analysis to assess the predictive value of different variables (patient factors, injury factors and social factor) to outcome.

The correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. Disc injury severity showed highest predictive value for both pain (29%) and functional (16%) outcomes, whereas the bony injury severity parameters (kyphosis, etc.) and the posterior ligament injury severity provided no prediction of outcome. According to AO classification, the fractures were A1, A2, A3 and B1; in this spectrum of injuries, the AO classification had no prediction of outcome. The disc injury score also had a good predictive value for final disc degeneration.

Disc injury severity should be gauged in advising prognosis and treatment. The new disc injury severity grading system showed good construct validity.

Recent work has demonstrated that intra-operative contamination of spinal surgical wounds is relatively common. The most frequently isolated wound contaminants are Propionibacterium spp. and coagulase negative Staphylococcus spp. The aim of this study is to examine the efficacy of prophylactic antibiotics used for spinal surgery against bacterial contaminants isolated from intra-operative samples retrieved during spinal surgical procedures.

Intra-operative wound samples were taken from 94 patients undergoing spinal surgery. Samples including skin, subcutaneous tissue and wound washings were processed, inoculated onto agar and incubated under both aerobic and anaerobic conditions for a period of 2 weeks. Bacterial growth was identified using commercially available biochemical test galleries. Thirty-six bacterial isolates were identified. The predominant bacteria isolated included Propionibacterium spp. (n=21) and coagulase negative Staphylococcus spp. (n=15). Each bacterial isolate was tested for its susceptibility to antibiotics used as antimicrobial prophylaxis during spinal surgery. Antibiotic sensitivities were determined in accordance with National Committee for Clinical Laboratory Standards (NCCLS) guidelines.

The antibiotic that performed best against Staphylococcus spp. isolated was ciprofloxacin with 93% of isolates being susceptible to this antibiotic. Cefamandole and cefuroxime also performed well against Staphylococcus spp. isolates.

The antibiotic that performed best against Propioni-bacterium spp. isolates was cefamandole with 100% of isolates being susceptible. Cefuroxime and ciprofloxacin also performed well. The antibiotic that performed least well against bacterial isolates was erythromycin with only 76% of Propionibacterium spp. and 47% of Staphylococcus spp. exhibiting susceptibility.

The results of this study demonstrate that ciprofloxacin, cefuroxime and cefamandole are effective against the majority of Propionibacterium spp. and Staphylococcus spp. isolated from within the spinal wound during surgery. The use of erythromycin in the penicillin allergic patient is questioned and ciprofloxacin proposed as a possible alternative.

Background context: Stable thoracolumbar spinal fracture is a common injury, yet there remains a relative lack of evidence that would allow reliable prediction of outcome. Variation in outcome in stable thoracolumbar spine fracture without neurological deficit could not be explained by the assessment made from x-rays and CT imaging alone, which measures mainly the bony injury severity. So far, no good classification system has been developed to assess the severity of soft tissue injury (disc).

Objectives: To measure short-term outcome of stable thoracolumbar fracture and analyse aspects of injury severity for their ability to predict outcome. To develop a new disc injury severity grading system in thoracolumbar spine fractures.

Study design: Prospective observational.

Patient sample: 44 patients with stable fractures between T11 and L5 vertebra with no neurological deficit and treated conservatively were selected.

Methods: All had plain x-rays, CT and MRI scans post-injury and at one year post-injury (except CT). Bony injury severity was scored on a seven-point ordinal scale based on (a) communication, (b) apposition and (c) kyphosis. Disc injury severity was scored by the newly developed six-point ordinal scale (none to severe) based on the following variables: (a) Herniation of the disc, (b) Indentation of the end plate, (c) Change in height and (d) Change in signal. Outcome was assessed at one to two years from injury. The following outcome measures were collected: (A) Five domains of pain symptoms – intensity, duration, bothersome, interference and satisfaction. (B) Five domains of function – Physical Component Summary (PSC) measure, Mental Component Summary (MSC) measure, Oswestry disability score, return to pre-injury level of overall activities and return to employment. Non-parametric correlation coefficients were calculated between outcome variables and other variables to look for the predictors of outcome. Stepwise linear regression analysis was performed to compare the predictive values and to look at what proportion of outcome is predicted by different predictors.

Results: According to AO classification, the fractures were A1, A2, A3 and B1. The Spearman correlation coefficients between outcome and injury severity were consistently higher with disc injury severity than bony. For the outcome of pain intensity, the correlation coefficients for disc and bone injury severity respectively were:.63 (p < .0001) and.28 (NS-not significant). Similarly for SF36 PSC were: .41 (p < .01) and.25 (NS). The predictive value of pain at F < .01 was 29% for disc injury severity and all other variable were not significant and excluded. At F < .05, the predictive value of disc injury severity (29%) increased further by 9%, 8% and 6% by addition of variable “Patient’s pre-injury SF36 MSC”, “Legal and Compensation issues pending” and “Physical demand of job” respectively. The predictive value of function at F < .01 was 16% for disc injury severity and it increased to 31% by the addition of “physical demand of the job” variable. At F < 0.05 the predictive value further increased by 5% by addition of variable “Legal and Compensation issues pending”. All other variables were not significant.

Conclusions: A new grading system of disc injury severity was developed and it showed good predictive value for pain and functional outcome. Disc injury severity has a better predictive value for short term outcome than bony injury severity in stable thoracolumbar fractures. In the spectrum of injuries studies, the AO classification and the degree of kyphosis provided no prediction of outcome.

Study Design: In a prospective study, intervertebral disc material from 64 patients undergoing discectomy for sciatica and 23 control patients was analysed for the presence of bacteria.

Objective: There have been many theories postulated as to the pathogenesis of back pain and sciatica. Possible inflammatory or auto-immune aetiologies have been suggested. Stirling et al (2001) suggested a possible link between sciatica and bacterial infection by demonstrating the presence of bacteria in disc material from 19 of 36 patients with severe sciatica. Previously, we developed methods for improved detection of bacterial infection associated with failed hip implants (Tunney et al 1999).These techniques have now been applied to the detection of bacteria in intervertebral discs from patients with sciatica.

Outcome Measures: Bacterial culture and non-culture immunofluorescence microscopy, using specific monoclonal antibodies, were applied to intervertebral disc material for the detection of bacterial infection. The results were also compared with functional scores before and after surgery.

Results: This study found that 20% (n=13) of patients suffering from sciatica had culture-positive disc material compared to 9% (n=2) of controls. The anaerobe Propionibacterium acnes was the predominant bacterium isolated in both case and control groups. Bacteria were also identified in skin, wound tissue and wound washings in some patients.

Conclusions: We are unable to demonstrate an association between sciatica and infection (p=0.335). This study suggests that bacteria detected in retrieved disc material may result from skin contamination during surgery.

Study Design: Prospective observational study.

Objectives: To score the severity of injury to (a) vertebrae and (b) intervertebral discs following thoraco-lumbar fracture, and compare the two in their ability to predict clinical outcome at 1–2 years.

Methods: 44 patients with fractures between T11 and L5 without neurological deficit were treated conservatively. All had plain X-rays and MRI scans immediately and at one year post-injury. Bony injury severity was scored on a seven-point ordinal scale based on a) comminution, b) apposition and c) kyphosis. Disc injury severity was scored on a six-point ordinal scale based on a) change in signal, b) change in height, c) indentation /herniation. Outcome was assessed at one to two years from injury (av. 18.1 + 5.6 months) Non-parametric correlation coefficients were calculated between injury severity variables and outcome variables.

Outcome measures: Modified Oswestry disability questionnaires, SF-36 questionnaires (physical and mental component summary scores – PCS and MCS), verbal and numeric rating scale of ability to perform pre-morbid activities/work. Detailed analysis of a.) pain (intensity, duration, character, distribution, etc.), b.) early morning stiffness (severity, frequency, and duration).

Results: According to the AO classification, 25% of the fractures were A1 (wedge), 9% were A2 (split), 45% were A3 (burst) and 20% were B1 (flexion-distraction with posterior ligament injury). Disc injuries scored as: grade 3 (mild) in 14%, grade 4 in 36%, grade 5 in 36% and grade 6 (very severe) in 14%. The spearman correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. For the Oswestry disability score the correlation coefficients for disc and bone injury severity respectively were 0.50 (p< .0001) and 0.40 (p< .05), for SF36-PCS: 0.43 (p< .005) and 0.32 (p< .05), for SF36-MCS: 0.43 (p< .005) and 0.06 (NS), for return to pre-morbid activities and work: 0.32 (p< .05) and 0.25 (p< .5), for pain intensity by numeric rating scale: 0.69 (p< .0001) and 0.41 (p< .01), and for pain intensity by verbal rating scale: 0.65 (p< .0001) and 0.28 (p< 0.1).

Conclusion: In all clinical outcomes assessed, there was consistently better prediction by measures of injury severity to the disc than the bone. This study offers possible explanation for previously low or conflicting evidence of correlation between clinical outcome and bony injury in thoraco-lumbar spine fractures uncomplicated by neurological injury. It implies that in selected patients with severe disc injury, treatment focused on eliminating the effects of the disc injury may result in better clinical outcome.

Introduction The purpose of this study is to present the results of the fi rst 28 cases operated on by one of the authors.

Methods The study is a prospective single cohort study. The technique is applicable to approximately half of the adolescent idiopathic cases requiring surgery in a busy spinal deformity practice. Clinical radiological and patient derived outcome data was collected pre-operatively and at six weeks, three months, 12 months and 24 months post-operatively. The series comprises 27 females and one male. The median age was 18 years (range 10 to 46). A median of four portals was used (range 3 to 5), six discs were excised (range 4 to 8) and seven levels were instrumented (range 5 to 9). Operating time was a median of 5.5 hours (range 4 to 7). Median blood loss was 450 ml (range 20 to 2000 ml).

Results Rib humps were corrected from a mean of 160° to 60°. The Cobb angle was converted from a mean of 55° to a mean of 21°: a correction rate of 62%. Sagittal alignment has improved: the sagittal plumb line moving a mean of two centimetres anteriorly. A significant improvement in outcome from a pre-op median of 59 to a post op median of 67 as measured by the SRS instrument has been observed. Follow-up is for a mean of 12 months (range 1 to 25). There has been one case of rod breakage at one year. This has not affected the clinical outcome and this case has now been followed for two years. There has been one case of frozen shoulder involving the dependant intra-operative shoulder that resolved after several months. There has been no blood transfusion and no loss of correction in any case to date.

Conclusions The thoracoscopic technique has proven safe and effective. A more cosmetic wound is achieved and the trunk muscles are spared. One or two levels in the thoraco-lumbar spine are spared from fusion.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction: The purpose of this study is to present the current results of a series of 21 cases operated on over the past two years. This is the only series of this type in Australia to date. Although the technique was first reported four years ago, two year results have not been reported or published.

Methods: This study is a prospective single cohort study. The technique is applicable to approximately half of the adolescent idiopathic cases requiring surgery in a busy spinal deformity practice. Clinical radiological and patient derived outcome data are collected pre-operatively and at six weeks, three months, 12 months and 24 months post operatively.

Results: The series comprised 17 females and 1 male. Median age was 16 years (range 10–37). A median of four portals was used (range 3–5), six discs excised (range 4–8) and seven levels instrumented (range 5–9). Operating time was a median of 6 h (range 4.5–7). Median blood loss was 300 ml (range 20–2000). Mean intra-operative x-ray time was 160 s (range 130–190). Rib hump was corrected from a mean of 170 to 70. The Cobb angle was converted from a mean of 510 to a mean of 240, a correction rate of 52%. There has been no loss of correction in any case to date. Further to the minor complications outlined last year there has been one case of persistent postoperative deltoid pain from the dependant shoulder that resolved after several days.

Discussion: The thoracoscopic technique has proven safe and effective. A more cosmetic wound is achieved and one or two levels in the thoracolumbar spine are spared from fusion.