Aim:

To Determine Whether Maximal Rib Prominence Measured On Lateral Radiographs Can Be Used As A Surrogate To Rib Rotation Determined By Surface Tomography (Quantecscanning) In Assessment Of Spinal Rotation.

Study Design

An observational study in patients with congenital spinal deformity.

Patients with peripheral primary bone tumours are often identified and referred at an early stage to a regional tumour service according to established guidelines. In patients with primary bone tumours of the spine, however, the definitive management or outcome of such patients is being prejudiced by preliminary intervention from non-specialist services prior to their referral.

Objective: To audit the standards of management of patients with primary bone tumours of the spine referred to a regional tumour service.

Retrospective review of case notes and radiology.

Subjects: Patients with primary bone tumour of the spine managed at the Orthopaedic Spine Unit with the Regional Bone Tumour Service in Newcastle Upon Tyne Hospitals NHS Trust.

Referral to tumour service, prior intervention, operative treatment, survival, factors affecting definitive management

31 of 39 (16 benign, 23 malignant) patients were initially referred from primary care to services other than the regional tumour service, most commonly neurosurgery (11/39) and paediatric oncology (4/39). Seven of 39 of these patients had undergone interventions prior to their referral to the tumour service, which may have negatively impacted their definitive management or curative surgery.

These tumours present complex issues regarding their definitive management to optimise outcome. Closer links between departments are required to enable the multidisciplinary management of primary bone tumours of the spine. Prior surgical intervention may compromise cure. Those involved in their management should be encouraged to liaise with their regional bone tumour service to improve outcome.

Following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000 and recommendation from International Commission on Radiological Protection (ICRP), the establishment of diagnostic reference levels (DRLs) for all radiological examinations became mandatory. There are no recommended or published standards or national dosage guidelines in the UK of diagnostic reference levels available for fluoroscopy-guided diagnostic and therapeutic spinal procedures. The aim of this study is to establish reference dose area product (DAP) levels for the diagnostic spinal procedures requiring fluoroscopy as a basis for setting DRLs.

All patient data consisted of diagnostic spinal procedures done in 2009 at Newcastle General Hospital under care of 4 spinal surgeons. Radiation data were collected on specific type of the procedure, DAP and screening time. Nerve root blocks, facet joint blocks and facet joint rhizolysis were included for data collection and analysis for this study. The third-quartile values were used to establish the DRLs.

There were 387 nerve root blocks with a mean exposure per injection 171.3 cGycm² (range, 3.0 to 2029.1; third quartile 209.4). Facet joint injections were 669 at a mean radiation dose 41.3 cGycm² (range, 1.9 to 541.0; third quartile 48.9). In a total 430 facet joint rhizolysis, the mean exposure was 44.4 cGycm² (range, 7.7 to 154.5; third quartile 58.4). The mean screening times were 36.7s (range, 0.4-281s; third quartile 41s) for nerve root blocks, mean 11.2s (range, 1.8-37s, third quartile 13.3s) for single facet joint block and mean 14.6s (range, 0.1-162s, third quartile 15.1s) for single facet rhizolysis.

We found the third-quartile values for setting DRLs for single level nerve root block, single facet joint block and single facet joint rhizolysis to be 209.4, 48.9 and 58.4 cGycm² respectively. We recommend that all spinal units in the UK should establish their own local DRLs to help in establishing national dosage guidelines for fluoroscopy-guided diagnostic and also therapeutic spinal procedures.

The Walter Reed Visual Assessment Scale (WRVAS) is a valid and reliable tool, designed to measure physical deformity as perceived by patients with idiopathic scoliosis. It is unclear whether the type of treatment in patients with thoracic adolescent idiopathic scoliosis affects the patients' perception of cosmesis gain. We studied 40 patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with (20) and without thoracoplasty (20) aiming to assess correlation of improvement in radiological parameters to subjective cosmesis gain.

Patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with thoracoplasty (20) and without thoracoplasty (20) filled out Walter Reed Visual Assessment Scale (WRVAS) forms with their perception of deformity before and after operation at the clinic follow-up. The WRVAS forms include seven aspects of the deformity i.e. spinal deformity, rib prominence, lumbar prominence, thoracic deformity, trunk imbalance, shoulder asymmetry and scapular asymmetry. Each aspect is shown with five figures of increasing severity of the deformity and scored from minimum (1) to maximum (5). Results are presented as the sum of the seven questions. The lowest possible score for the total is 7, while the highest possible total score is 35. The curve magnitude was divided into 5 subgroups as 30 and under, 30-40, 40-50, 50-60 and 70 and over.

Floor and ceiling effects were analysed as percentage of cases with minimum and maximum scores.

Our study confirmed that following posterior scoliosis surgery with and without thoracoplasty, there was significant improvement in perceived appearance. Overall spinal deformity and thoracic deformity correction were comparable in two groups. However, improvement in rib hump prominence, flank prominence, restoration of truncal, shoulder and scapular symmetry were much better rated by the patients with PSF and thoracoplasty group using Walter Reed Visual Assessment Scale.

Proponents of thoracoplasty suggest a better correction, obviating iliac crest donor site morbidity, obtaining bone grafts for fusion and better rib hump correction. Opponents suggest increase risk for chest complications, additional operating time and blood loss, and possible longer hospital stay. There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

It is a retrospective study of consecutive series of 62 patients with thoracic adolescent idiopathic scoliosis surgically treated by single surgeon between 2007 and 2008 at a tertiary referral Orthopaedic Spinal unit. Posterior spinal fusion and thoracoplasty (n=32, all but one girls) were compared with 30 without thoracoplasty (all but one girls). Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 3-months, 1 year and/or 2-year follow-up, and comparisons were made between two groups. The minimum follow-up was one year.

No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up ranging 1 to 3 years. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients compared to patients treated by posterior spinal fusion alone. Three-month postoperative pulmonary function test values in both groups experienced 15-30% decline which returned to the preoperative baseline at 1 year in > 90% patients. In thoracoplasty group, 5 to 8 ribs were resected and used for bone graft. Chest complications were observed in 2 patients requiring chest drainage. Prolonged donor site morbidity was noted in 3 patients.

Thoracoplasty showed comparable clinical and radiological correction without any significant pulmonary function compromise. Pulmonary function test values returned to the preoperative baseline at 1 year in > 90% patients.