The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.

Introduction

We present our experience of 22 patients with low grade degenerative lumbar spondylolysthesis with stenosis (21 Grade I and 1 Grade II) who were treated using new stabilization systems {Scient'x IsoBar TTL Dynamic Rod Stabilization and the Inlign™ Multi-Axial pedicle Screws (Disc Motion Technologies - DMT)}.

To examine the relationship between obesity (BMI> 30) and the incidence of peri-operative complications, outcome of surgery and return to work in patients undergoing elective less invasive posterior lumbar inter-body fusion of the lumbar spine for low back pain and leg pain (“LI-PLIF”).

15 patients with BMI> 30 who underwent (“LI-PLIF”) were identified by reviewing the clinical notes and the pre-operative admission sheet from April 2005- to March 2007. All had suffered chronic low back pain for a minimum of 2 years that had proven unresponsive to conservative treatment. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). Minimum follow-up was for 12 months.

Blood loss was dependent on BMI, number of levels, and surgical time. Post operative complication was more in the morbidly obese group than the in the obese. 10 patients (66.6%) returned to their normal pre-operative employment within the 12 months of the index procedure. There was a significant improvement in the ODI and in the VAS for back pain. Length of hospital stay was a mean of 3.3 days

Although surgery is technically more demanding our experience with less invasive posterior inter-body fusion has shown less incidence of post operative complication, less intra-operative blood loss and short in-patient hospital stay.

We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain.

Ethics approval: None: Audit Interest Statement None

The aim of this study is to review the functional outcome of the patients treated with Posterior Lumbar Interbody Fusion for FBSS.

This is a retrospective review of prospectively collected data of 39 patients diagnosed with FBSS and treated with PLIF between June 2000 and December 2008 by the senior author in our unit. Pain and function were evaluated by VAS for Back (VAS-BP) & leg pain (VAS-LP), Oswestry disability index (NDI) and SF-36 questionnaires, and were completed pre- & post-operatively.

There were 39 patients (20 women & 19 men) and mean age at operation was 47.3 years (range of 32 to 76.1 years). Mean duration of follow-up was 39.14 months (range 5.21 -73.5 months). Thirty-one patients were diagnosed as Post laminectomy syndrome and 8 patients as post-discectomy syndrome.

The mean pre and post-operative ODI values were 54.13 and 29.14 respectively. The mean pre-operative VAS back and leg pain scores were 7.38 and 6.51 respectively. The mean post-operative VAS for back and leg pain scores were reduced to 4.05 (Pre-op:7.38) and 3.69 (Mean pre-op 6.51)respectively. The mean preoperative SF-36 bodily pain component score was 27.42 and the mean postoperative score was 40.50.

Four patients had uncomplicated dural tears that resolved completely. Two patients had superficial wound infection that resolved with oral antibiotics.

PLIF is one of the safe and effective treatment option for FBSS and it has shown good results in our series.

Recurrence of back or leg pain after discectomy is a well-recognised problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success. In this study, 42 patients with recurrent symptoms after discectomy underwent less invasive posterior lumbar interbody fusion (LI-PLIF). Clinical outcome was measured using the Oswestry Disability Index (ODI), Short Form 36 (SF-36) questionnaires and visual analogue scales for back (VAS-BP) and leg pain (VAS-LP). There was a statistically significant improvement in all outcome measures (p < 0.001). The debate around which procedure is the most effective for these patients remains controversial.

Our results show that LI-PLIF is as effective as any other surgical procedure. However, given that it is less invasive, we feel that it should be considered as the preferred option.

Failed Back Surgery Syndrome (FBSS) refers to having persistent back and/or leg pain after one or more surgical procedures aimed at correcting lumbosacral disease. Different modalities including Epidural injections, Spinal cord stimulation, Anterior/Posterior Lumbar Interbody Fusion (ALIF, PLIF) have been described in the literature with varying outcome. Our aim was to review the functional outcome of patients treated with Posterior Lumbar Interbody Fusion for FBSS since June 2000 to December 2006.

This is a retrospective study of prospectively collected data of 25 patients diagnosed with FBSS and treated with PLIF at University Hospital of North Tees. All patients were requested to fill in the Oswestry Disability Index(ODI), Numerical Rating Scale for Back Pain (NRSBP), Numerical Rating Scale for Leg Pain (NRSLP), SF36 pre and post operatively. The scores were analysed using SPSS software for statistical significance.

There were 12 men and 13 women. Mean age was 47.8 years (range 31–76 years). Mean follow up was 24.8 months (range 4 – 63 months). Four of the 25 patients had Post discectomy syndrome while the rest had post laminectomy syndrome. Most common level of surgery was L5/S1 either as a single level or in combination with other levels above. ODI decreased from a pre-op mean of 55.6(range 20–74.1) to 20.6(range 2–54) while VASBP decreased from 6.9 (range 1–9) to 2.2(range 0–6) (p< 0.05) and VASLP decreased from 6.4 (range 3–10) to 2.2 (range 0–7) (p< 0.05). SF36BP scores improved from a mean 26.7 (range 12–37.1) before the surgery to 45 (range 31–62) (p< 0.05) after surgery. 84% of the patients felt that the outcome of the surgery met their expectation and were satisfied with result.

Our results show that PLIF can be offered as a safe and effective for treatment of FBSS.

Purpose: To assess the outcomes in consecutive 32 patients of two level cervical disc replacement

Methods: In this article, we report 2-year results of anterior cervical decompression and two level cervical disc replacements (prestige) in 32 patients with a diagnosis of symptomatic cervical spondylosis. Dynamic assessment with lateral radiographs of the cervical spine in flexion/extension was done pre and post op. All of them had partial uni/bilateral uncinectomy, which adds in lateral bending. The median age of all patients was 46 years (range 32–61). Levels of surgery included between seven C3–C7, most common were C5–6, C6–7.

Results: Neck and arm pain as well as disability scores (VAS, ODI and SF36) were significantly improved by 3 months and remained improved at 2 years. Radiography revealed the complete motion (From flexion to extension) at upper disc replacement level of 11% and 9.6% at the lower level. There is a significant decrease of the facet joint articulation overlap in the sagittal plane. As the diameter of socket is slightly larger than the ball in prestige disc replacement, it helps in additional axial movement. There was reduction in motion at the adjacent segments above and below, preventing adjacent segment problems.

Conclusion: Twenty-four months after surgery, patients who underwent two level cervical disc replacements demonstrated greater improvement in neurologic function and neck pain. It helps in restoring sagittal balance, functional outcome of patient because of increased lateral bending, axial rotations and flexion-extension.

Ethics approval: done from appropriate authorities

Interest Statement: There is no local grant, national grant, commercial/industry support for this article. There are no interest or gain from any source for this article.

Purposes: To evaluate the effectiveness of Posterior Lumbar Interbody Fusion (PLIF) surgery in resolving back and back related leg pain and its effect on quality of life.

Methods: Two hundred and twenty six patients who met the inclusion criteria of degenerative disc disease, spondylolisthesis, disc herniation and postlaminec-tomy/postdiscectomy syndrome unresolved by conservative therapy were entered into the study. Patients were assessed using a self-administered questionnaire containing the Oswestry disability index (ODI) for back pain related disability, visual analogue scales (VAS) for back and leg pain severity (0 = none, 10 = worst imaginable pain) and the SF-36 general health questionnaire. Outcomes were assessed preoperatively and at a minimum of 2 years follow-up. Statistical significance was tested using a paired t-test after confirming normality of the data.

Results: Of the 226 patients,182 (99 females, 83 males; mean age at treatment, 45.3 years; age range 15 – 67 years) returned follow-up questionnaires (81% response). The mean duration of follow-up was 26.4 months (range 24 – 60 months). The ODI showed a statistically and clinically significant improvement between baseline (52.1) and follow-up (29.5), (22.6(17.8 to 27.5); P= 0.000). This represents a 43% improvement in functional ability. There was a statistically and clinically significant improvement between VAS back pain scores at baseline (7.7) and follow-up (3.9), (3.8 (3.1 to 4.4); P = 0.000 ). This represents a reduction of 49%. Similarly VAS leg pain at baseline (6.6) and follow-up (3.2) ,(3.4 (2.7 to 4.2); P = 0.000) showed a reduction of 52% which was also statistically and clinically significant. All dimensions of the SF-36 except role physical showed a statistically and clinically significant improvement.

Conclusion: The results show that in our series, there is a statistically and clinically significant improvement in pain, functional ability and quality of life after PLIF surgery in patients with chronic back and leg pain unresolved by conservative therapy.

Purposes: To evaluate the effectiveness of Posterior Lumbar Interbody Fusion (PLIF) surgery in resolving back and back related leg pain and its effect on quality of life.

Methods: Two hundred and twenty six patients who met the inclusion criteria of degenerative disc disease, spondylolisthesis, disc herniation and postlaminec-tomy/postdiscectomy syndrome unresolved by conservative therapy were entered into the study. Patients were assessed using a self-administered questionnaire containing the Oswestry disability index (ODI) for back pain related disability, visual analogue scales (VAS) for back and leg pain severity (0 = none, 10 = worst imaginable pain) and the SF-36 general health questionnaire. Outcomes were assessed preoperatively and at a minimum of 2 years follow-up. Statistical significance was tested using a paired t-test after confirming normality of the data.

Results: Of the 226 patients,182 (99 females, 83 males; mean age at treatment, 45.3 years; age range 15 – 67 years) returned follow-up questionnaires (81% response). The mean duration of follow-up was 26.4 months (range 24 – 60 months). The ODI showed a statistically and clinically significant improvement between baseline (52.1) and follow-up (29.5), (22.6(17.8 to 27.5); P= 0.000). This represents a 43% improvement in functional ability. There was a statistically and clinically significant improvement between VAS back pain scores at baseline (7.7) and follow-up (3.9), (3.8 (3.1 to 4.4); P = 0.000 ). This represents a reduction of 49%. Similarly VAS leg pain at baseline (6.6) and follow-up (3.2) ,(3.4 (2.7 to 4.2); P = 0.000) showed a reduction of 52% which was also statistically and clinically significant. All dimensions of the SF-36 except role physical showed a statistically and clinically significant improvement.

Conclusion: The results show that in our series, there is a statistically and clinically significant improvement in pain, functional ability and quality of life after PLIF surgery in patients with chronic back and leg pain unresolved by conservative therapy.

Object: To study the incidence, etiology and management of patients with neuralgia following Posterior Lumbar Interbody Fusion (PLIF).

Design: A prospective study of 216 patients undergoing PLIF surgery from March 1996 to August 2003.

Subjects: 16 of the 225 patients (7.1%) undergoing PLIF surgery developed new leg pain following surgery.

Results In all patients, the distribution of the postoperative pain was different than the pre-operative pain. Nerve swelling with relative stenosis was the most common cause (9/16), followed by pedicular screw misplacement (2/16), nerve anomaly (2/16), loose posterior arch (2/16), and graft subsidence (1/16).

Nine patients with nerve swelling complained of pain with no neurological findings. One responded to a root block and 6 to re-exploration and further decompression. The patients with misplaced screws woke up from surgery with pain and neurology. The pain responded to removal of screws in both. Two patients with loose posterior arches complained of leg pain while lying down only. These symptoms disappeared after excision of the arches. In 2 patients conjoint roots were found intra-operatively. Both developed post operative pain, which settled down in one. In one patient subsidence of an iliac graft caused pain a few months following surgery and did not respond to further decompression.

Discussion: The overall incidence of post PLIF neuralgia was 7.1%, however by removing the whole facet, as performed in the last 122 patients, the incidence reduced from 9.7% (first 103 patients) to 4.9%. Based on our data we propose a classification system for Post PLIF Neuralgia, and a management plan. Using both, 11 of the 16 patients reported their leg pain disappeared, leaving only 5 patients with residual leg pain (< 3%). Key-stones in avoiding post PLIF neuralgia are generous decompression of the nerve roots, especially the lateral recess above the disc, total facetectomy and removal of graft pieces before closure.

Introduction: Vertebroplasty is an established minimally invasive technique, which provides consistent and sustained pain relief in patients with vertebral fractures. However cement extrusion remains a major problem and has been reported to occur in up to 70% of the cases in some reports. Cement extravasations may occur through the Basivertebral vein, the Segmental vein or through cortical defects. Cement leakage may be Epidural, Anterior, Para-vertebral, Intra-discal or distant. Most often cement leakage is asymptomatic but on occasion it may be a serious complication in the form of Cord compression, pulmonary embolism or Neuralgia.

The incidence of cement leakage can be reduced by the use of high viscosity cement, use of a low pressure injection system, injecting small volumes at each level, introducing the cement under visualization and waiting for cement to set before withdrawing the needle.

Patients and Methods: We describe another technique to help in reduction of cement extrusion.

After satisfactory placement of the Jamshidi needle (used for injecting cement), aspiration is attempted using a 20ml Syringe. A slurry, made of very fine pieces of Gel foam mixed with Omnipaque dye and saline, is injected into the vertebral body. This embolizes the blood channels, which are communicating with the needle. Once no more blood can be aspirated, and no dye is seen extruding into the veins, toothpaste consistency cement is injected under low pressure and fluoroscopic guidance. A post-procedure CT scan was performed in all cases to confirm cement location.

Results: 28 patients underwent PV, 24 of these patients had osteoporotic vertebral fractures and 4 had meta-static lesions. Vertebroplasty was done at 56 symptomatic levels. Using this method, Cement leakage was seen at 12 of the 56 levels operated on (21.4%); at 6 levels leakage was into the adjoining disc, leakage anteriorly was seen at 3 levels, there was 1 leakage into the paravertebral tissues and at 2 levels there was a streak of cement into the vertebral canal in 1 via the venous system and in the other through a cortical defect. None of the leakages were symptomatic. Epidural leakage was seen in 2 patients (3.57%).

Conclusion: A slurry of gelfoam, dye and saline injected prior to cement reduces the incidence of cement extrusion, therefore increasing the safety of this effective procedure.

Objective : To share our experience developing an integrated spinal service, including a Spinal Assessment Clinic (SAC), Data Collection Centre, self-help Spinal Fitness Programme, three month Multi-disciplinary Spinal Rehabilitation Programme surgical service and Spinal Support Group. The Service was commended in the National Nye Bevan Awards and won the Millennium Nurse of the Year award surgical category.

Design: The SAC has operated for three and a half years and includes two nurse practitioners and an extended scope physiotherapist. Over 1000 patients per year are assessed, investigated, educated and commenced on a management plan by the practitioners, including data collection pre and post treatment. The three-month Rehabilitation programme is based in a sports complex and runs in collaboration with the private sector. The patients seen by MK are fully investigated and have failed conservative measures. The patient-led Spinal Support Group counsels all patients prior to treatment, feeding back related problems. The sole consultant (MK) has developed formal links with another spinal surgeon combining operating, clinical and audit sessions.

Outcome measures: Reduced out-patient waiting times, patient satisfaction survey, discharge rate following self-help Spinal Fitness Programme, number of complaints.

Results: Waiting time reduced from 89 to 16 weeks, urgent cases are seen within twenty-four hours. One hundred patients polled by questionnaire: 70% regarded their experience through SAC as excellent, 28% good and 2% fair. 70% were discharged six months following the self- help Spinal Fitness Programme. SAC had three complaints in three years, none for a missed diagnosis.

Conclusion: We would commend this service model for consideration by our colleagues.

Objective: Assess outcomes following a three-month multi-disciplinary spinal rehabilitation program for chronic low back pain, based in the community in a £10 million sports centre.

Design: This was a prospective study with data being collected before and at the completion of the programme. The programme team consists of an orthopaedic surgeon, physiotherapists, fitness instructor, nurse counsellor and a secretary. The programme included a graded aerobic fitness programme, spinal stabilisation programme, cognitive behavioural therapy, hydrotherapy and occupational therapy.

Subjects: 112 patients with chronic mechanical back pain. Mean duration of symptoms 9.1 years. Mean age was 46 years: 52 women and 60 men.

Outcome Measures: Included visual analogue score, Oswestry Disability Score (OSW), lumbar motion velocity, shuttle walking test, lifting endurance, isometric strength of spinal extension and flexion and the return to work rate.

Results: Mean VAS back pain and leg pain scores reduced from 6.6 to 4.1 and 3.7 to 2.2 respectively (p< 0.001). Mean OSW decreased from 34.6% to 21.7% (p< 0.001). Back pain improved by 37% and the Oswestry score by 42%. Only three of the 112 patients went on to have surgery. Mean lumbar motion velocity improved from 114 to 161 degrees/second (P< 0.001). Shuttle walking test improved from 458 to 644 metres (p< 0.001). Mean lifting maximum improved from 16.1 to 19.3Kg (p=0.005). Lifting endurance improved from 51 to 38 seconds. Mean Isometric spinal extensor strength improved from 24.2Kg to 48.6Kg and flexion from 25.7 to 49.4Kg (p< 0.001 in all cases). Thirty-eight percent of patients were unemployed before the program and 10% after the program. Patients also reported needing less analgesia, having more confidence, feeling happier and their flare-ups settling more quickly.

Conclusions: This three-month programme delivered significant improvements in back pain, disability, strength and endurance capacity and a return to work rate, in this cohort of chronic back pain patients.

Object: To study the incidence, etiology and management of patients with neuralgia following Posterior Lumbar Interbody Fusion (PLIF).

Design: A prospective study of 85 patients undergoing PLIF surgery from March 1996 to March 2001.

Subjects: Seven of the 85 patients undergoing PLIF surgery developed new leg pain between three days and five months following surgery.

Results: The incidence of neuralgia was 8%. In all the patients the post-surgical neuralgia was in a new distribution. MRI examination ruled out misplaced pedicle screws in all cases, but was otherwise unhelpful. One patient developed neuralgia five months post-operatively due to collapse of the cortico-cancellous graft and secondary foraminal narrowing. This was not relieved following surgical decompression. Four patients had neuralgia caused by relative stenosis of the exiting nerve (3) or the traversing nerve (1) which started between three days and two weeks after surgery. The pain was relieved in all four following surgical decompression. One patient had leg pain when lying down; standing and sitting relieved this. A loose lamina was found on exploring the wound. Her pain settled after surgery. One patient developed a spondylolisthesis at the level below a L4/5 PLIF four months after surgery. Her pain was eased by stabilization of the lower segment.

Conclusions: MRI scans are not very helpful in these cases. Early exploration is recommended and gave good results in six of our seven cases.

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot.