Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

There is limited long term evidence to support instrumented fusion as an adjunct to decompression for foraminal stenosis in the presence of single level degenerative disc disease.

We report the long term outcome of a prospective randomised controlled trial. Forty-four patients with single-level disc disease were randomly assigned to three groups (spinal decompression (Group 1), decompression and instrumented posterolateral fusion (Group 2), or decompression and instrumented posterolateral fusion plus transforaminal interbody fusion (Group 3). Spinal disability (Dallas, Roland Morris, and Lower Back Outcome Score [LBOS]), and quality of life (EuroQol (EQ) and short form (SF-) 36 questionnaires) were assessed before and at after surgery by independent researchers.

At mean of 15 years follow up 33 (75%) patients were available for assessment. All groups observed a significant improvement in the EQ-5D at final follow up. Group 1 demonstrated significantly better functional outcome at final follow up according to the Dallas, Roland Morris, LBOS, and EQ-5D (3L and VAS) scores when compared to the other two groups (p<0.01). The SF-36 score demonstrated that group 1 had significantly better generic health scores compared to groups 2 and 3. Regression analysis was used to adjust for the differences in general health between the groups and demonstrated no significant difference between the groups in the spine specific scores: Dallas (p>0.15), Roland Morris (p>0.37), or the LBOS (p>0.32).

Fusion in combination with decompression for the treatment of foraminal stenosis and single level degenerative disc disease offers no long term functional benefit over decompression in isolation.

There is a paucity of published literature regarding the long-term outcomes of the modern generations of total joint arthroplasty (TJA) of the first metatarsophalangeal joint. Between 1999 and 2001, we recruited 63 patients into a randomised controlled trial of arthrodesis vs TJA. The 2 year results were published in 2005.

At a mean follow-up 15.2 years (range 13.2–17.2), all patients from the original trial were contacted. Data were collected in the form of visual analogue score for pain (VAS), visual-Analogue-Scale Foot and Ankle (VAS FA) as well as information on any revision procedures.

Data were available from all surviving patients (66 toes 53 patients). There was no difference in pain scores between the arthrodesis group and arthroplasty group 7.4 ± 15.7 vs 15.7 ± 19.7 (p=0.06). There was also no difference in the VAS FA scores as a whole 88.9 ± 12.9 vs 86.1 ± 17.1 (p = 0.47), or when divided into its 3 components (pain, function and other complaints). There was however a significant difference with regards to patient satisfaction with the arthrodesis group outperforming the TJA group: 95.5 ± 10.4 vs 83.6 ± 20.9 (p<0.01). There was a significantly higher rate of revision surgery in the TJA group when compared to the arthrodesis group (p= 0.009).

At 15 years the patients that underwent arthrodesis were more satisfied and had a greater survivorship compared to TJA, however there was no difference in outcome with regards to pain or function between the two groups. Based on the results of this study arthrodesis remains the ‘gold standard’ due to excellent pain relief, high function and low risk of revision surgery.

Growth rods are currently used in young children to hold a scoliosis until the spine has reached a mature length. Only partial deformity correction is achieved upon implantation, and secondary surgeries are required at 6-12 month intervals to lengthen the holding rod as the child grows. This process contains, rather than corrects, the deformity and spinal fusion is required at maturity. This treatment has a significant negative impact on the bio-psychosocial development of the child.

Background

Degenerative spondylolisthesis (DS) with stenosis is now typically treated by decompression and instrumented fusion. This treatment method does produce predictable results at the spondylolisthetic level, but later stenosis will occur commonly at the adjacent level due to the rigidity of the construct. Pedicle screw fusion may also be a significantly invasive procedure for an elderly patient.

To assess the effectiveness of unilateral sublaminar and concave rib tethering with convex rib resection through the period of peak growth in lambs.

Morphometric growth data from 10 experimental Scottish Blackface sheep were compared to those from 5 control animals (no intervention) over 12 months.

Standardized AP and Lateral radiographs were taken before and at monthly intervals after scoliosis creation. The Cobb angle was measured in the coronal and sagittal planes. Rotational mal-alignment was assessed by axial CT 7 months post surgery.

In the supine position the control animals had no coronal plane deformity and a mean 5° lordosis (T4-T12). These figures did not alter with growth (doubling of body weight). Tethering (at age 5 weeks) produced an immediate scoliosis of 22±11° and a lordosis of 24±8° (means(sd). The degree of scoliosis was maintained over 7 months (at 20°) but lordosis increased (to 59±11°, p<0.01). There was an associated change in vertebral rotation. Surgery had no influence on rate of growth or animal development.

Two animals died from Clostridium associated enterocolitis. There were no deaths associated with the surgical intervention.

This ovine model gives a progressive spinal deformity in the sheep but primarily in the sagittal plane. This fact should be considered in studies designed to evaluate the effectiveness of surgical implants.

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro)

48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery.

Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated.

25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES).

Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery.

To investigate whether restoration of mechanical function and spinal load-sharing following vertebroplasty depends upon cement distribution.

Fifteen pairs of cadaver motion segments (51-91 yr) were loaded to induce fracture. One from each pair underwent vertebroplasty with PMMA, the other with a resin (Cortoss). Various mechanical parameters were measured before and after vertebroplasty. Micro-CT was used to determine volumetric cement fill, and plane radiographs (sagittal, frontal, and axial) to determine areal fill, for the whole vertebral body and for several specific regions. Correlations between volumetric fill and areal fill for the whole vertebral body, and between regional volumetric fill and changes in mechanical parameters following vertebroplasty, were assessed using linear regression.

For Cortoss, areal and volumetric fills were significantly correlated (R=0.58-0.84) but cement distribution had no significant effect on any mechanical parameters following vertebroplasty. For PMMA, areal fills showed no correlation with volumetric fill, suggesting a non-uniform distribution of cement that influenced mechanical outcome. Increased filling of the vertebral body adjacent to the disc was associated with increased intradiscal pressure (R=0.56, p<0.05) in flexed posture, and reduced neural arch load bearing (F_N) in extended posture (R=0.76, p<0.01). Increased filling of the anterior vertebral body was associated with increased bending stiffness (R=0.55, p<0.05).

Cortoss tends to spread evenly within the vertebral body, and its distribution has little influence on the mechanical outcome of vertebroplasty. PMMA spreads less evenly, and its mechanical benefits are increased when cement is concentrated in the anterior vertebral body and adjacent to the intervertebral disc.

Background: Several recent studies have compared incorporation of autograft with that of allograft or synthetic bone substitutes in anterior cervical discectomy and fusion (ACDF). These studies have almost universally relied on plain radiography to assess bone incorporation despite the fact that we know, from similar lumbar spine studies, that bone ingrowth is over-estimated.

Our aim was to determine the exactly whether bone incorporation may be correctly assessed by this method by comparing the results to those obtained by spiral CT imaging.

Methods: 15 patients underwent ACDF. Helical CT scans were obtained. Fusion was defined as trabecular continuity across the disc space anterior, through and posterior to the cage proximally and distally and assessed by two of the authors independently.

Results: 14 of the 15 patients appeared to have solid incorporation of bone graft/substitute on plain radiography, 19 out of 20 cages. These findings were not however replicated on CT imaging. The autograft was not considered to have been incorporated proximally above the cage in 5 cases and distally in 6 cases.

Discussion: The implication of our results is that there is at least a false positive rate of bone incorporation of 20–25%. Pseudarthroses are generally painful and therefore we would recommend that spiral CT imaging is performed in patients who have ongoing pain following ACDF.

Ethics approval: COREC Ethics committee number 06/S1104/34

Interest Statement: None of the authors have received any grants to carry out this research.

Introduction: Vertebroplasty increases stiffness and partly restores normal load-sharing in the human spine following vertebral fracture. The present study investigated whether the mechanical effects of vertebroplasty are influenced by the distribution of injected cement.

Methods: Ten pairs of cadaver motion segments (58–88 yr) were loaded to induce fracture, after which one from each pair underwent vertebroplasty with polymethyl-methacrylate cement, the other with a resin (Cortoss). Various mechanical parameters were measured before fracture, after fracture and following subsequent vertebroplasty. Micro-computed tomography scans and plane radiographs (sagittal, frontal, and axial) obtained from each augmented vertebral body were analysed to determine percentage cement fill in the whole vertebral body and in selected regions. The relationship between volumetric fill obtained by micro-CT and areal fill obtained by radiography was investigated using linear regression analysis. Regression analysis also indicated whether changes in mechanical parameters following vertebroplasty were dependent upon cement distribution.

Results: Cement type had no significant influence upon regional fill patterns, so data from both cements were pooled for all subsequent analyses. Volumetric fill of the whole vertebral body was predicted best by areal fill in the sagittal plane (R2=0.366, P=0.0047). Restoration of intradiscal pressure and compressive stiffness following vertebroplasty were dependent upon volumetric cement fill both in the whole vertebral body (R2=0.304, P=0.0118 and R2=0.197, P=0.0499 respectively), and in the anterior half (R2=0.293, P=0.0137 and R2=0.358, P=0.0053).

Conclusion: Cement fill patterns can best be assessed radiographically from sagittal plane views. Placement of cement in the anterior vertebral body may help to improve mechanical outcome following vertebroplasty.

Joint arthroplasty is increasingly being promoted by commercial companies for hallux rigidus. We report the preliminary results of a randomised controlled trial comparing metatarsophalangeal joint arthroplasty with fusion.

63 patients, 14 with bilateral disease (39f, 24m; mean age 55, range 34–77) were recruited and assessed independently. They were then allocated by closed opaque envelope to receive either a condylar joint replacement (BIOMET®) or toe arthrodesis (circlage and oblique K-wire). Outcome assessments were repeated at 6 months, 1 and 2 years (2 fusion, 1 implant lost to follow-up at 1yr).

All 38 fusions finally united (3 were delayed > 4 months) at a mean angle of 26±7° dorsiflexion. Two patients were admitted for K-wire extraction under GA and seven required courses of antibiotics. Six of the first 30 arthroplasties had on-going pain and erythema following surgery. One had a sympathetic dystrophy but the remaining five had evidence of phalangeal component loosening and were readmitted for a one stage cemented revision (4 aseptic and 1 septic loosening). The phalangeal component was cemented on the final 9 occasions (Palacos® + Gentamicin). No further revisions have been required. At 1yr 80% of patients rated their fusion and 72% their arthroplasty good/excellent (VAS pain score: pre: 63±18 -v- 59±19, n.s; 1yr: 18±24 -v- 38±27 p< 0.05 means±SD).

Patients are generally pleased to retain joint mobility, but the high incidence of phalangeal component loosening probably will require a change in implant design / surface coating.

We measured the effect of arthroscopic lavage and debridement of the osteoarthritic knee by comparing objective measurements of thigh muscle function before and after operation. There was some improvement in quadriceps isokinetic torque at six and 12 weeks after joint lavage but not after debridement. Neither method significantly relieved the patients' symptoms.

1. Correction of hallux valgus by spike osteotomy of the neck of the first metatarsal is described, and the results in eighty-two feet are presented.

2. A high proportion of satisfactory results can be obtained, but great care is needed in both selection and technique.

3. The ideal case is one of moderate deformity, without degenerative arthritis, and with symptoms referable to increased width of the forefoot; the operation should not be performed in cases with obvious degenerative change, nor when metatarsalgia is a prominent symptom.

4. It is important to displace the metatarsal head as far laterally as possible, and vital to avoid dorsal angulation or displacement.

5. It is suggested that enough is now known about the natural evolution of hallux valgus and the results of some operations for prophylactic surgery to be undertaken in carefully selected cases.