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The Bone & Joint Journal
Vol. 98-B, Issue 11 | Pages 1427 - 1430
1 Nov 2016
Powell JM Rai A Foy M Casey A Dabke H Gibson A Hutton M

Many hospitals do not have a structured process of consent, the attainment of which can often be rather ‘last-minute’ and somewhat chaotic. This is a surprising state of affairs as spinal surgery is a high-risk surgical specialty with potential for expensive litigation claims. More recently, the Montgomery ruling by the United Kingdom Supreme Court has placed the subject of informed consent into the spotlight.

There is a paucity of practical guidance on how a consent process can be achieved in a busy clinical setting. The British Association of Spinal Surgeons (BASS) has convened a working party to address this need. To our knowledge this is the first example of a national professional body, representing a single surgical specialty, taking such a fundamental initiative.

In a hard-pressed clinical environment, the ability to achieve admission reliably on the day of surgery, in patients at ease with their situation and with little likelihood of late cancellation, will be of great benefit. It will reduce litigation and improve the patient experience.

Cite this article: Bone Joint J 2016;98-B:1427–30.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVI | Pages 74 - 74
1 Jun 2012
Berry CL Cumming D Hutton M
Full Access

Aim

To assess whether oncologists are adhering to the NICE guidelines on MSCC.

Methods and Results

All patients who received radiotherapy for metastatic spinal cord compression from 1st June 2009 – 1st June 2010 were identified. This information was then compared to the data collected via the MSCC Coordinator. The notes and radiological investigations were reviewed by the spinal consultant.

34 patients received radiotherapy for MSCC, 15 patients were not referred to the spinal team prior to radiotherapy. On reviewing each individual case 2 patients may have potentially benefited from surgical intervention.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 33 - 33
1 Apr 2012
Bucher T McCarthy M Redfern A Hutton M
Full Access

To determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool

Radiological analysis.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

Reproducibility of the measurements was assessed using Bland and Altman plots. Accuracy was assessed using the Vernier calliper measurements as the gold standard and comparing the plots.

Perfect reproducibility was achieved when measuring the geometric objects with the Vernier callipers. The error of the measurement associated when measuring the pedicles was 0.5mm. The error of the measurement for the geometric objects for observers 1 and 2 was 0.5 and 0.6mm respectively, and for the pedicles it was 1.0 and 0.6mm respectively.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.

Ethics approval None Interest Statement None


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XII | Pages 16 - 16
1 Apr 2012
Bucher T McCarthy M Redfern A Hutton M
Full Access

Pedicle screw systems are now the commonest method of achieving posterior spinal fixation. Surgical planning in spinal surgery may include measuring pedicle size to guide screw size on WEBPACS. We performed a study to determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 104 - 104
1 Apr 2012
Berry C Clarke A McCarthy M Hutton M Osbourne M
Full Access

Peninsula Spinal Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK.

A retrospective audit in 2000 of cases presenting with metastatic cord compression (MSCC) was conducted. In June 2009 we introduced the role of MSCC coordinator. We present the preliminary results from a 6 month comparative audit and discuss whether implementation of the NICE Guidelines have improved the care pathway.

Prospective cohort study with retrospective controlled group.

Adults with suspected MSCC

Length of time to MR imaging

% referred for surgical opinion

Length of time on bed rest.

% undergoing surgery

Retrospective audit 2000

38 cases confirmed MSCC.

11 did not have MRI and were treated on the basis of clinical symptoms.

Average time from admission to MRI 42 hours.

8 patients (21%) referred for surgical opinion.

None had surgery

38 had radiotherapy.

Spinal stability documented on 1 patient.

5.5 days average bed rest

Prospective audit 2009

54 patients referred to co-ordinator as suspected MSCC.

52 had MRI and 2 had CT.

Average time from referral to MRI 41 hours.

Average time for patients with neurological deficit 7.6 hours.

54 patients (100%) referred for surgical opinion.

12 patients had surgery (22%).

100% patients had spinal stability documented.

Average length of time on bed rest 2 days.

It is uncertain whether these results are attributed to the introduction of the NICE guidelines or improved awareness of condition. However we feel that NICE guidelines have improved the care pathway of patients with MSCC.

Statement of ethics and interests: Study was approved and registered with audit department.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 26 - 26
1 Apr 2012
Clarke A Thomason K Emran I Badge R Hutton M Chan D
Full Access

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.

Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system.

Recurrence of spinal metastasis and radiological failure of reconstruction

All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications.

Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 484 - 484
1 Aug 2008
Hutton M Hay D Powell J Sharp D
Full Access

Introduction: This study investigates the effect of somatisation on results of lumbar surgery.

Methods: Pre- and postoperative data of all primary discectomies and posterior lumbar decompressions was prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year.

Results: There were a total of 320 patients (average age 49.7 years). Preoperatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up.

All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively).

At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers.

The postoperative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0).

The postoperative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5). In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7).

These differences are statistically significant.

Discussion: Patients with features of somatisation are severely functionally impaired preoperatively. One year following lumbar spine surgery, 60%(28) had improved psychologically, 23%(11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14(30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 233 - 233
1 Sep 2005
Hutton M Bayer J Sawant M Sharp D
Full Access

Study Design: Retrospective review of 55 subjects who for various clinical indications had sequential MRI scans

Summary of Background data: Changes in the vertebral end plate are frequently associated with degenerative disc disease. These are called Modic changes. The changes were first classified into two types. Type I changes include decreased signal intensity on T1-weighted and increased signal intensity on T2-weighted images. In type II, signal intensity is increased in both T1- and T2-weighted sequences. Type I changes are assumed to be a result of fibrovascular replacement of subchondral bone and type II changes are the manifestation of fatty replacement of subchondral bone and are considered to be chronic. These changes can be separated only on magnetic resonance imaging (MRI). If bone sclerosis is extensive, signal intensities are decreased in both T1- and T2- weighted images, and this change in the end plate is called type III change. It is again assumed that these endplate changes represent a process that is progressive (Type I converts to Type II converts to Type III). To our knowledge there is little evidence to support such assumptions.

Objective: To investigate the hypothesis that Modic changes are a progressive degenerative process.

Subjects: The average time interval between MRI scans was two years. No subjects had had surgical intervention. The lumbar vertebral endplates were classified using the Modic system and the results compiled to provide further data on the natural history of these endplate changes.

Results: Of the endplates that had Modic type I changes on the first MRI scan, 6% had reverted to a normal MRI endplate appearance on subsequent scan. Of those with Modic type II appearance 18% were normal or type I on subsequent scan.

Conclusions: This data would not support the hypothesis that Modic changes observed on MRI are a progressive degenerative process.