Background

The British Orthopaedic Association Standards for Trauma (BOAST) for peripheral nerve injuries¹ states:

This study investigated whether this standard was met for patients with upper limb trauma at a busy London Accident and Emergency (A&E) Department.

We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up implanted between October 1999 and May 2002. Revision of either the femoral or acetabular component during the study period is defined as failure. No other revisions have been performed or are impending. We had 4 failures giving us survivorship at 5 years of 97% (95% confidence interval (CI) 94 – 100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35 – 75). All patients were followed up clinically and radiographically.

The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16 – 57) to 15.3 postoperatively (Range 12 – 49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1 – 10) to 7.54 postoperatively (Range 4 – 10) p< 0.001.

Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112 – 148) with average cup alignment of 36 degrees (Range 22 – 47). Neck thinning was present in 12 hips (10%) and we define a technique for measuring thinning. Heterotropic ossification was present in 17 hips and lucent lines around the femoral component in 10 hips.

This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients. It is the first study with a minimum 5 year follow up from outside the originating centre.

Introduction: Preliminary results of the Birmingham Hip Resurfacing Arthroplasty were promising. The first series with minimum 5 year follow up was published in 2005 and came from the designing centre. Survivorship and functional results were good. This is the first series with a minimum 5 year follow up not from the designing centre.

Methods: All patients who underwent BHR between the dates of October 1999 and May 2002 were included in the study.

Results: We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up. Revision of either the femoral or acetabular component during the study period is defined as failure. We had 4 failures giving a survivorship at 5 years of 96.5% (95% confidence interval (CI) 93–100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35–75). All patients were followed up clinically and radiographically.

The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16–57) to 15.3 postoperatively (Range 12–49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1–10) to 7.54 postoperatively (Range 4–10) p< 0.001.

Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112–148) with average cup alignment of 36 degrees (Range 22–47). Neck thinning was present in 16 hips (14%) and we define a technique for measuring thinning.

Discussion: This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients.

Purpose of Study: To determine whether pre operative psychological assessment can be used to predict the outcome following intradiscal electro thermal therapy (IDET).

Materials and Methods: Patients undergoing IDET at our unit were asked to complete a pain diagram and a Short Form 36 (SF36) (UK Version 1). Patients were followed up after IDET by means of a postal questionnaire. Patients outcome was assessed using a visual analogue pain score (VAS), an SF36 and a subjective outcome assessment. Pain drawings were classified as organic and non-organic according to the principle described by Mann et al.

Results: Forty-six (80.7%) patients were successfully followed up. Mean age was 41.2 years (range 16–76), 27 were female and 19 male. 73.9% of the pain diagrams were classified as organic and 26.1% as non-organic. The pain diagram was a good predictive tool for outcome following IDET. Patients with ‘organic’ pain drawings showed an improvement in mean pain VAS (pre 6.7, post 5.9), high patient satisfaction (Better 67.6%, Same 11.8%, Worse 20.6%), and higher physical component scores of the SF36 (Physical 64.1, Physical Role 45.6, Pain 54.0) compared to the ‘non-organic’ group who demonstrated a deterioration in mean pain VAS (pre 6.5, post 8.2), low patient satisfaction (Better 8.3%, Same 58.3%, Worse 33.3%), and lower physical component scores of the SF36 (Physical 38.3, Physical Role 20.8, Pain 26.5).

Conclusions: Several authors have shown that certain preoperative psychological characteristics are associated with a poor outcome from spinal surgery. Our findings suggest that pre procedure psychological assessment is useful in predicting which patients will have a favourable outcome from IDET. Pain drawings are quick and easy for patients to complete.

It might be a useful predictor in most of the spine surgery. We have incorporated pain diagrams in the questionnaires of patients undergoing anterior spinal surgery and dynamic stabilisation of spine.

Objective To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion.

Method 60 patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of the operation at the end of the procedure. VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively independently. The total dose of morphine required was recorded.

Results The patients randomised to receive fentanyl showed a decrease in their mean VAS scores as well as a 40% reduction in the total morphine dose delivered. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment. All patients left recovery after 2 hours to be nursed on an open ward.

Conclusion Intrathecal fentanyl is effective at reducing mean pain VAS scores and morphine use via a PCA after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.

Objective A prospective longitudinal study with a mean 22 month follow up (range 6–36 months) to assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electrothermal therapy (IDET).

Method Patients with a discogenic origin of their back pain confirmed by diagnostic imaging and discography and who underwent IDET were included in the study. Discographic reproduction of symptoms with subsequent abolition with local anaesthetic led to inclusion in the study regardless of discogram volume. Outcome was assessed using VAS pain scores, Oswestry Disability Index (ODI) scores, employment status, subjective outcome and pain diagrams.

Results 68 patients were treated with IDET. 51 patients were successfully followed up for a minimum of one year, of whom 31 had at least 2 year follow up. These patients were divided into two groups. Group 1 consisted of 29 patients aged less than 40 with single level disease, no facet joint arthritis, a low volume positive discogram and an organic pain diagram. Their mean VAS scores decreased from 7.52 to 3.84 (p< 0.001). 70% reported a good or excellent outcome with only 30% fair or poor. Group 2 included the remaining 22 patients. Their mean VAS decreased from 7.41 to 6.13 and only 32% reported a good or excellent outcome with 68% fair or poor.

Conclusion We conclude that with very strict selection criteria, IDET can have a successful outcome.

Objective: To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion. Morphine has been shown to be effective intrathecally in spinal surgery but there is an increased incidence of respiratory complications. Fentanyl has not been formally evaluated in this setting.

Design: This was a prospective randomized double blind trial. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomized to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of operation at the end of the procedure.

Subjects: 30 patients undergoing lumbar spinal surgery were prospectively recruited.

Outcome measures: VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively. Time to first bolus delivery of morphine from the PCA was also recorded as was the total dose of morphine required.

Results: The patients randomized to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only 2 patients required HDU observation overnight. The rest of the cohort left recovery after 2 hours to be nursed on an open ward.

Conclusion: Intrathecal fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.

Introduction and Aims: To assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing spinal surgery.

Method: Sixty patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of operation at the end of the procedure. VAS pain scores were then taken at two, four, 24 and 48 hours post-operatively. Time to first bolus delivery of morphine from the PCA was also recorded, as was the total dose of morphine required.

Results: The patients randomised to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine, as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only two patients required HDU observation overnight. The rest of the cohort left recovery after two hours to be nursed in an open ward.

Conclusion: Intrathecal Fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients in the open ward

Study Design: Prospective randomized double blind trial.

Objective: To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion.

Summary of Background Data: Morphine has been shown to be effective intrathecally in spinal surgery but there is an increased incidence of respiratory complications. Fentanyl has not been formally evaluated in this setting.

Methods: All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon under direct vision one or two levels above the site of operation at the end of the procedure.

Subjects: 30 patients undergoing lumbar spinal surgery were prospectively recruited.

Outcome measures: VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively. Time to first bolus delivery of morphine from the PCA was also recorded as was the total dose of morphine required.

Results: The patients randomized to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only two patients required HDU observation overnight. The remainder of the cohort left recovery after 2 hours to be nursed on an open ward.

Conclusion: Intrathecal fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.

Purpose of Study: To determine whether preprocedure psychological assessment can be used to predict the outcome following intradiscal electrothermal therapy (IDET).

Materials and Methods: Patients undergoing IDET at our unit between April 2000 and March 2002 were asked to complete a pain diagram and a Short Form 36 (SF36) (UK Version 1). Patients were followed up after IDET by means of a postal questionnaire. Patients outcome was assessed using a visual analogue pain score (VAS), an SF36 and a subjective outcome assessment. Pain drawings were classified as organic and non-organic according to the principle described by Mann et al.

Results: Forty-six (80.7%) patients were successfully followed up. Mean age was 41.2 years (range 16–76), 27 were female and 19 male. 73.9% of the pain diagrams were classified as organic and 26.1% as non-organic. The pain diagram was a good predictive tool for outcome following IDET. Patients with ‘organic’ pain drawings showed an improvement in mean pain VAS (pre 6.7, post 5.9), high patient satisfaction (Better 67.6%, Same 11.8%, Worse 20.6%), and higher physical component scores of the SF36 (Physical 64.1, Physical Role 45.6, Pain 54.0) compared to the ‘non-organic’ group who demonstrated a deterioration in mean pain VAS (pre 6.5, post 8.2), low patient satisfaction (Better 8.3%, Same 58.3%, Worse 33.3%), and lower physical component scores of the SF36 (Phsical 38.3, Physical Role 20.8, Pain 26.5).

Conclusions: Several authors have shown that certain preoperative psychological characteristics are associated with a poor outcome from spinal surgery. Some authors have demonstrated a correlation between these characteristics and pain diagrams when they are judged as ‘organic’ and ‘non-organic’. Our findings suggest that preprocedure psychological assessment is useful in predicting which patients will have a favourable outcome from IDET.

Pain drawings are quick and easy for patients to complete. Our study demonstrates pain drawings can reliably be used to predict outcome following intradiscal electrothermal therapy.

Purpose of Study: It has been widely reported that smokers undergoing lumbar spinal surgery are more likely to develop postoperative complications such as pseudarthrosis, superficial and deep wound infection, as well as diminished clinical improvement. New spine instrumentation was developed (SpineLinkTM, Biomet) which enables surgeons to fuse multiple levels by linking single level fusions in series. This is accomplished through titanium links and polyaxialscrews which preserve lordosis without the bending of rods or plates. During an ongoing 5 year prospective investigation on fusion with intrasegmental fixation the authors analysed and compared outcomes in smokers versus non-smokers to determine the impact of this new system on outcomes in smokers.

Materials and Methods: 64 patients who underwent spine fusion with intrasegmental fixation were prospectively studied at Mayday University Hospital beginning in 1997, 54 have sufficient follow-up to be included in the analysis. Patients were assessed pre and postoperatively, both radiographically and clinically, using validated outcome instruments including the SF-36.

Results: There were 54 patients in the analysis (34 patients in the smoker group and 20 patients in the non-smoking group) with an average age of 52 years and an average follow-up of 28 months. 32 patients had multilevel procedures (25 two level, 5 three level, 2 four level). The treatment groups were comparable with respect to demographic, diagnostic (53% spondylolisthesis, 35% degenerative disc disease, 12% other) and surgical variables. No other significant medical problems affected patients in either group. Radiographically there were no pseudarthroses observed in either group. The SF-36 physical health score increased from 22.4 to 40.1 (+18.0) following surgery in smokers compared to an increase from 25.0 to 36.0 (+11.0) in non-smokers. The SF-36 mental health score increased from 36.4 to 45.0 (+8.6) in smokers compared to an increase of 30.8 to 42.7 (+2.9) in non-smokers. Complications included 2 nerve root injuries requiring hardware removal, and 3 deep infections which resolved with appropriate treatment.

Conclusions: There were no differences between smokers and non-smokers in radiographic fusion success or postoperative complications. As expected, smokers had lower SF-36 physical health and mental health scores pre-op, but unexpectedly, smokers had a greater degree of improvement in these scores postoperatively than non-smokers. Thus, from our experience, there is an incremental benefit to the use of intrasegmental fixation in smokers and warrants further investigation.

Purpose of Study: To prospectively study the outcome of lumbar interbody fusion with an intrasegmental device, and to determine whether smoking, previous surgery and multiple level surgery have an effect on fusion rate.

Methods Used: Between October 1998 and July 2001, 67 patients underwent lumbar interbody fusions using an intrasegmental pedicle screw system (Biomet, Spinelink). Prior to surgery Short Form 36 (UK Version 1) (SF36) scores, pain visual analogue scores (VAS) and patient demographics were recorded. Postoperative follow up was in a specialist spine clinic. Patients were followed up in this clinic until fusion was judged to have occurred both clinically and radiographically. Fusion was judged to have occurred radiographically when there was evidence of a fusion mass at all fused levels and absence of pedicle screw loosening and/or metal work breakage. Patients who were not judged to have fused were classified as either a pseudarthrosis, or indeterminate. Patients completed a questionnaire on attendance at clinic, or by post if discharged. This included an SF36, Oswestry Disability Index, employment status, analgesic use and patient satisfaction assessment.

Results: 67 patients (38 male and 29 female) were successfully followed up. The mean age was 45.2 (range 17–86). Mean follow up was 21.7 months (range 12–43 months). 36 posterolateral fusions and 31 combined posterior lumbar interbody/posterolateral fusions were performed. 22 patients were smokers and 45 non-smokers or ex-smokers at the time of surgery. 18 patients had undergone previous surgery (either discectomy, decompression or fusion). 34 patients had 2 vertebral levels fused, and 33 patients more than 2 vertebral levels.

There was radiographic evidence of fusion in 81.3% of patients. There was an improvement in mean pain VAS, and mean scores of all physical components of the SF36. Patient satisfaction was high (71%).

Subgroup analysis demonstrates that the fusion rates in non-smokers versus smokers, and primary fusions versus previous surgery, were the same. The fusion rate following multiple level fusions was lower at 72.2%.

Conclusions: The results of our study suggest that high fusion rates can still be achieved in high risk patients when an intrasegmental device is used.