The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed. Research in the 1980s suggested that pain sensation was conducted in part via the sympathetic system. These sensory pathways have now been clarified using sophisticated experimental and histochemical techniques confirming a dual pattern. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry through the thoracolumbar white rami communicantes.

Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission.

The nature and mechanism of discogenic pain is still speculative but there is growing evidence to support a ‘visceral pain’ hypothesis, unique in the muscloskeletal system. This mechanism is open to ‘peripheral sensitisation’ and possibly ‘central sensitisation’ as a potential cause of chronic back pain.

Objective: Senior author conducted two studies focusing on the age of presentation, Cobb angle at presentation and means of detection of adolescent idiopathic scoliosis in 1976 and 1985 respectively. We conducted another similar study in 1999 to compare the present situation with the previous two studies.

Design: Data was collected for 100 consecutive cases of adolescent idiopathic scoliosis which presented to the scoliosis clinic at The Middlesex Hospital, London from 1997 to 1999. the age of presentation, Cobb angle at presentation and the person who detected the deformity first were recorded. The patients were divided in following groups.

Group1 detected by family and friends.

Group2 detected by GP or by another doctor incidentally.

Group3 detected at school.

Group 4 detected by teachers.

Subjects: There were 81 female and 19 male patients with a mean age of 13.8 years.

Results: Group 1 consisted of 63% of the patients. Group 2 had 26% of the patients. Group 3 compromised of 8% of the patients and group 4 had 3% of the patients. Group 1 was the largest group and had increased since 1985 and 70% of the patients in this group had a Cobb angle greater than 40 degrees at presentation. It was also noted that group 3 had significantly dropped to 8% while in 1985 and in 1976 it was 10% and 32% respectively.

Conclusions: Our results represent a small sample from one center but it clearly shows that detection of scoliosis at school has dropped and majority of the cases are detected by family and friends often at a later stage with larger Cobb angles in excess of 40 degrees. Non-operative methods are ineffective with Cobb angles of this magnitude thus highlighting the importance of some means of early detection of scoliosis and producing greater awareness in the community.

We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months.

The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing.

The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity.

Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass.

In a prospective trial we performed MRI of the spine and hind brain in 31 patients with scoliosis of onset between the ages of four and 12 years.

In eight patients (26%) there was a significant neuroanatomical abnormality; there were six cases of Chiari-1 malformation associated with a syrinx, one isolated Chiari-1 malformation and one astrocytoma of the cervical spine. Four of these patients had left-sided curves.

There were no clinical features which could reliably identify those patients with abnormalities on MRI. In particular, the unilateral absence of abdominal reflexes was found to be non-specific (1 of 8 of patients with neuroanatomical abnormalities (12.5%) v 2 of 23 with normal scans (8.7%)).

In view of the established risks of surgical correction of scoliosis in the presence of undecompressed syringomyelia and the possible improvement that may follow decompression of the foramen magnum, we feel that MRI of all patients with scoliosis of juvenile onset should be obligatory.

1. Passive straight-leg raising may induce pain in the back or leg or a combination of both in patients with acute lower lumbar disc lesions. Clinical, myelographic and operative observations were carried out prospectively in fifty such cases to investigate the relation of the pattern of pain on straight-leg raising to the site of the protrusion.

2. In patients with central protrusion straight-leg raising induced mainly back pain. In patients with intermediate protrusion, lying in contact with both dura and nerve root, a combination of back and leg pain predominated. Patients with lateral protrusion usually experienced only pain in the leg. This correlation was found in 80 per cent of cases.

3. Production of pain in the leg by straight-leg raising is of practical significance in lateral protrusions where myelography may be normal.

4. Pain in the back and pain in the leg on straight-leg raising may be related respectively to dural and nerve root sensitivity.

1. Five cases of fibrosarcoma arising after radiotherapy in cases of ankylosing spondylitis are reported.

2. The relationship of the tumours to irradiation is discussed.

3. Objective neurological signs arising in the lower limbs of patients with ankylosing spondylitis after a latent period following radiotherapy may indicate an underlying sarcoma.