The UK's NIHR and Australia's NHMRC have funded two randomised controlled trials (RCTs) to determine if lumbar fusion surgery (LFS) is more effective than best conservative care (BCC) for adults with persistent, severe low back pain (LBP) attributable to lumbar spine degeneration. We aimed to describe clinicians’ decision-making regarding suitability of patient cases for LFS or BCC and level of equipoise to randomise participants in the RCTs. Two online cross-sectional surveys distributed via UK and Australian professional networks to clinicians involved in LBP care, collected data on clinical discipline, practice setting and preferred care of five patient cases (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were also asked about willingness to randomise each patient case.Background and Purpose
Methods
Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination.Aims
Methods
Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted. As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients.Aims
Methods
Children undergoing posterior spinal fusion (PSF) for neuromuscular and syndromic scoliosis were admitted to the paediatric intensive care (PIC) until about 6 years ago, at which time we created a new unit, a hospital floor-based spinal high-dependency unit-plus (SHDU-plus), in response to frequent bed-shortage cancellations. This study compares postoperative management on PIC with HDU-plus for these non-hospital floor suitable children with syndromic and neuromuscular scoliosis undergoing PSF. Retrospective review of 100 consecutive children with syndromic and neuromuscular scoliosis undergoing PSF between June 2016 and January 2022. Inclusion criteria were: 1) diagnosis of syndromic or neuromuscular scoliosis, 2) underwent PSF, 3) not suitable for immediate postoperative hospital floor-based care. Exclusion criteria were children with significant cardio-respiratory co-morbidity requiring PIC postoperatively. 55 patients were managed postoperatively on PIC and 45 on SHDU-plus. No significant difference between groups was found with respect to age, weight, ASA grade, preoperative Cobb angles, operative duration, number of levels fused and estimated blood loss. 4 patients in the PIC group and 1 in the SHDU-plus group were readmitted back to PIC or HDU following step-down to the hospital floor. Average length of stay was 2 days on PIC and 1 day on SHDU-plus. Average total length of hospital stay was 16.5 days in the PIC group and 10.5 days in the HDU-plus group. 19 (35%) patients developed complications in the PIC group, compared to 18 (40%) in SHDU-plus. Mean specialist unit charge per day was less on SHDU-plus compared with PIC. There were no bed-shortage cancellations in the SHDU-plus group, compared to 11 in the PIC group. For children with neuromuscular or syndromic scoliosis undergoing PSF and deemed not suitable for post-operative care on the hospital floor, creation of a SHDU-plus was associated with fewer readmissions back to PIC or HDU, shorter hospital stays, an equivalent complication rate, significant cost-saving and fewer cancellations. Level of Evidence: Therapeutic Level III.
The lordosis distribution index (LDI) describes distribution of lumbar lordosis, measured as the % of lower lumbar lordosis (L4-S1) compared to global lordosis (L1-S1) with normal value 50–50%. Maldistributed LDI is associated with higher revision in short lumbar fusions, 4 vertebrae1. We hypothesise maldistributed LDI is also associated with mechanical failure in longer fusions. Retrospective review of 29 consecutive ASD patients, aged 55+, undergoing long lumbar fusion, 4 levels, with >3-years follow-up. LDI, pelvic incidence (PI) and sagittal vertical axis (SVA) were measured on pre- and post-op whole spine standing X-rays (Fig A and B). Patients were categorized according to their pelvic incidence (PI) and postoperative LDI: Normal (LDI 50 80), Hypolordotic (LDI < 50), or Hyperlordotic (LDI > 80) and assessed for failure rate compared to normal LDI and PI <60. Mean follow-up 4.5 years. 19 patients had mechanical failures including junctional failure and metalware fracture. PI >60o was associated with higher mechanical failure rates (Chi^2 p<0.05). Hypolordotic LDI was associated with 82% mechanical failure (Chi^2 p<0.001), Hyperlordotic 88% mechanical failure (Chi^2 p<0.001) and Normal 8% mechanical failure (Table 1). Maldistributed LDI, whether Hyperlordotic or Hypolordotic, correlated with 10× greater mechanical failure rate compared to Normal LDI in long fusions. LDI is a useful measurement that should be considered, especially in high PI patients.
Dual-mobility constructs (DMCs) are increasingly used for total hip replacement (THR) following hip fracture. The aims of this study were to identify whether there was a difference in all-cause construct survival following THR with a DMC (DMC-THR) or with a conventional construct following hip fracture, and to identify the expected net all-cause construct survival for DMC-THR performed for hip fracture. We performed a systematic review and meta-analysis of published studies (including joint registries) including DMC-THR for hip fracture which provided Kaplan-Meier (KM) survival estimates. The primary outcome was all-cause construct survival over time. 318 papers and 17 registry reports were identified. Three studies (two registry reports and one cohort study utilising joint registry data) met the inclusion criteria, including 8,834 DMC-THRs and 63,865 conventional THRs. Upon meta-analysis, DMC-THRs had lower all-cause construct survival. Five-year KM estimates (95% confidence intervals) were 95.3% (94.6–95.9%) for DMC-THR and 96.1% (95.9–96.3%) for conventional THR. These results suggest there is a small absolute but not clinically significant all-cause implant survival difference between THR with DMC and conventional implants following hip fracture. Given the higher comparative cost of DMC, this analysis does not support its routine use.
The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion.Aims
Methods
The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers.Aims
Methods
The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR. A retrospective review of data was performed at a tertiary spinal centre between 2018 to 2020. Data were collated from electronic patient records, theatre operating lists, and trust-specific BSR data. Information from the BSR included operative procedures (mandatory), patient consent, email addresses, and demographic details. We also identified Healthcare Resource Groups (HRGs) which qualified for BPT.Aims
Methods
This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication. A single group retrospective analysis.Objectives
Design
Neural axis anomalies in idiopathic scoliosis (AIS) are well documented, with prevalence of 7% in adolescents; 20% in early-onset and up to 40% in congenital, the case for pre-operative MRI of brainstem to sacrum is well made in these groups. SK is rarer than AIS and the prevalence of anomalies is not defined. The case for routine MRI scan is unclear. A recent report concluded that routine MRI was not indicated, although this was based on only 23 MRI scans in 85 patients. At our institution all patients are undergo whole spine MRI following a diagnosis of SK. We aimed to assess the incidence of significant neural anomalies in Scheuermann's Kyphosis. Using a keyword search for “Scheuermann”, we reviewed all SK patients' MRI reports over the past 6 years. 117 MRI scans were identified. 13 patients did not fulfil the radiological criteria for SK and thus 104 (73M: 31F) scans were reviewed. 14 (13%) of 104 scans showed unexpected Significant abnormal findings. There were 8 (8%) with neural axis anomalies: 4 syrinxes; 1 cord anomaly; 2 cerebellar descents and 1 cerebellar tumour. All these patients had normal neurological examination except one with examination consistent with a known diagnosis of Parkinson's. A further 6 patients had non-neural anomalies. The presence of neural axis anomalies may influence the management of a patient with SK. Neurological compromise during correction is higher in patients with neural axis anomalies and this risk can often be partially mitigated by a preceding neurosurgical procedure (such as foramen magnum decompression or shunt). Furthermore it is well described that these anomalies often occur in patients who demonstrate a normal neurological examination. This study confirms this. Given that MRI is widely available and considering the devastating life implications of neurological injury, we advise pre-operative MRI scan in all SK patents.
We describe the prevalence of spondylolisthesis in Scheuermann's Kyphosis (SK) from retrospective review of 104 SK patients over 6 years. All patients referred to our institution for symptomatic SK undergo MRI scan from hindbrain to sacrum. Our MRI database was reviewed for all SK patients. All scans with spondylolisthesis were re-analysed. 117 scans were identified, 13 patients did not fulfil the MRI criteria for SK and thus 104 (74M: 31F) scans of SK are reported. There were 5 spondylolisthesis (1 cervical and 4 lumbosacral). Of the 4 lumbosacral there were 2 Meyerding grade-1; 1 grade-2 and 1 grade-5 spondyloptosis). An overall rate of 5% for listhesis was therefore found. The prevalence of spondylolisthesis is around 3% in the general population based on a CT study of 510 patients (Belfi 2006) and Fredrickson's (1984 and 2003) prospective study of 500 children. We describe the prevalence in SK patients being higher at 5%. This may be related to the adaptive change of increased lumbar lordosis in SK, certainly it supports the previous description higher rates of spondylolysis in SK.
AIS causes a loss of trunk height. This paper documents this loss against sitting height standards and assesses formulae for adjusting height loss back to the standard. A total of 334 patients (84% female) with AIS and no other known systemic disease had sitting height measured. This was compared to standards of sitting height with age and the ratio of height to sitting height with age (HSH). The corrected height was calculated using published formulae and replotted against these standards.Aim:
Methods:
Ideally, a patient receiving a unicondylar knee replacement will have fully functional anterior and posterior cruciate ligaments. When at least one of the cruciate ligaments is not fully functional, femoral and tibial implant contact position can potentially increase along the anterior-posterior (AP) axis. Where unicondylar implant wear testing typically uses AP resistance assuming fully functional cruciate ligaments, the authors used reduced AP resistance intended to simulate deficient cruciate ligaments. Optetrak Logic® Uni (Exactech Inc, Gainesville, FL USA) unicondylar test specimens featuring an all-UHMWPE tibial component and a cobalt chromium femoral component were used in this study. The system has a semi-constrained articular geometry. Testing was conducted at an independent testing facility (EndoLab GMBH, Thansau, Rosenheim, Germany). A four-station knee simulator was used (EndoLab knee simulator) with two unicondylar knee implants per station, giving a total of eight test specimens. Two different tibial fixation designs (keeled and peg) with identical articulating surfaces were tested. Tibial test specimens were 6 mm in thickness. Unloaded soak controls were stored in distilled water at 37°C. The test was conducted according to ISO 14243–1: 2009 [1]. Test specimens were immersed in calf serum (PAA GmBH, Cölbe, LOT B00111-5126) with a protein content of 20 g/l. Custom polyurethane molds allowed for individual component measurement. Per the ISO 14243-1, a 7% medial offset was incorporated into the set-up. The unicondylar knee implants were set at neutral position in extension. Tibial rotational restraint was 0.36 Nm/° and zero when the test specimen was within ± 6° of the reference position. This test was conducted with an AP resistance of 9.3N/mm to maximize AP displacement and simulate deficient cruciate ligaments. Typical unicondylar knee wear testing is conducted with an AP resistance of 44N/mm, which assumes functional cruciate ligaments.Introduction
Methods
Monitoring of scoliosis is traditionally done with radiographs, which can be associated with an increased risk of cancer secondary to multiple exposures over many years. This study investigated whether the findings from surface topography can be used to monitor scoliosis curves and how much this method affects outcome scores in patients with scoliosis. This study therefore had two subsets: (1) to investigate whether lateral asymmetry (LA) from ISIS2 surface topography can predict radiographic Cobb angle, providing an alternative non-invasive means of monitoring patients with scoliosis (LA and Cobb subset); and (2) to establish the relationships between the magnitude of the deformity in scoliosis, measured by Cobb angle on radiograph and volumetric asymmetry (VA) with the ISIS2 surface topography, and the patient perception of self-image and mental health, measured with SRS-22 scores (Cobb, VA, and SRS subset). In the LA and Cobb subset, 72 untreated patients with scoliosis (77 curves) with a Cobb angle of 55° or less were included in the study. They had clinical assessment, Cobb angle measurement taken from a standard radiograph, and surface topography done on the same day. A comparison of Cobb angle and LA was done. In the Cobb, VA, and SRS subset, 89 untreated patients with scoliosis were included in the study. They had clinical assessment, Cobb angle measurement of radiograph, and surface topography done on the same day along with SRS-22 questionnaires. A comparison correlation of SRS scores for function, pain, self-image, and mental health against Cobb angle and VA was undertaken. All statistical analysis was done with software R.Introduction
Methods
To establish the relation between the magnitude of the deformity in scoliosis, measured by cobb angle on radiograph & Volumetric asymmetry with the ISIS2 surface topography, and the patient perception of self image and mental health, measured with SRS-22 scores. A total of 89 untreated patients with scoliosis were included in the study. They had clinical assessment, cobb angle measurement of radiograph and surface topography performed on the same day along with SRS-22 questionnaires. The cobb angle was measured by single surgeon using a digital PACS system, who was unaware of the volumetric asymmetry score. Volumetric asymmetry was measured by ISIS2 surface topography performed by a research nurse who was unaware of the cobb angle. Volumetric asymmetry was calculated using standard ISIS2 software. A comparison correlation of SRS scores for function, pain, self image and mental health against cobb angle and volumetric asymmetry was undertaken by clinical scientist. Scores for patient satisfaction to treatment was excluded as these were untreated patients. Statistical analysis was performed using cor. test on software RPurpose of the study
Methodology
Monitoring of scoliosis is traditionally done with radiographs which can be associated with an increased risk of cancer secondary to multiple exposures over many years. This study investigates whether lateral asymmetry (LA) from ISIS2 surface topography can predict radiographic cobb angle, to provide an alternative non- invasive means of monitoring scoliosis patients. A total of 72 untreated patients with scoliosis (77 curves) with a Cobb angle of 55 degrees or less were included in the study. They had clinical assessment, cobb angle measurement taken from a standard radiograph and surface topography done on the same day. The cobb angle were measured by single surgeon using digital PACS system. The surgeon was unaware of the LA score. Lateral asymmetry was measured using ISIS2 surface topography done by a research nurse who was also unaware of the cobb angle as previously described. Lateral asymmetry was calculated using the standard ISIS2 software. A comparison of cobb angle and LA was performed. Linear regression analysis was performed to define an equation predicting Cobb from LA. The predicted Cobb angles were then compared with the measured radiographic Cobb angles using Bland-Altman analysis. All statistical analysis was carried out using R.Purpose of the study
Methods
Reviewing our experience of scoliosis in children with a Cavopulmonary Shunt or Fontan circulation and the cardiovascular challenges that this presents. A notes and x ray review was performed. Special attention was paid to the changes in cardiovascular status whilst prone. The review was from first presentation to latest follow up. There were 6 patients who underwent 7 major procedures between 2001 and 2009. All had cardiac procedures in early life. Both definitive fusion and growing instrumentation was used. All procedures were successful. Growing instrumentation allowed earlier primary surgery before completion of the Fontan circulation. All have been subsequently lengthened in a lateral position. The mean follow up is 56 months. There was one death 40 months following last surgery, cause unrelated to spinal surgery. In the older patients with a completed Fontan significant blood loss was seen, due to the raised venous pressure required to run the Fontan, and occult hypotension seen as a climbing difference between Pulmonary Artery Wedge Pressure and Central Venous Pressure were common when prone. We recommend early intervention, using instrumentation without fusion to correct the deformity over time and allow intervention prior to completing the Fontan circulation. As haemodynamic instability increases with increasing time in the prone position, surgery should be expedited rapidly.
Spinal Deformity Service, Royal Orthopaedic Hospital, Birmingham, UK To describe the technique of nonfusion annulotomy and nuclectomy with posterior growing rod instrumentation for the treatment of non-congenital early onset scoliosis To present our results of the application of this technique in a consecutive series of nine patients with mean follow up of 76 months (range 16 to 123 months) We undertook retrospective observational casenote and radiograph study of patients with noncongenital early onset scoliosis having annulotomy and nuclectomy at the apex of their respective curves with standard posterior growing rod instrumentation between 1998 and 2009. 10 patients were identified with one excluded due to short follow up period. Of the nine patients included mean follow up was 76 months. Mean age at primary surgery was 71.7 months (range 29- 97 months) We measured pre and post operative Cobb angle, T1-S1 height change and change in height over the apical segments. Mean pre op cobb angle was 74° (range 62- 81°). Mean post op cobb angle was 38°. Three patients have completed their treatment programme with a mean number of 9 lengthenings achieved. Six patients are still undergoing lengthenings. CT demonstrates that the annulotmized segment does not fuse at a mean 3.5 years postoperatively. All patients demonstrated growth over total spinal height and also over apical segments which had undergone annultomy/ nuclectomy. We also report complications. We have demonstrated that anterior annulotomy and nuclectomy with posterior growing rod construct does allow for spinal growth over released segments without autofusion.
