Patients had traditionally relied on health care professionals for advice and treatment options for most orthopaedic conditions including degenerative lumbar spine disease. However the unprecedented access to heath care information offered by the internet is changing the way how patients gather information and make treatment choices.

Aims & Methods: The purpose of this study was to determine the influence of the internet on patients presenting to orthopaedic clinics with degenerative lumbar spine disease and its influence on decision making.

A power calculation was done to determine appropriate sample size needed for the study. Questionnaires were handed to willing patients who were attending back clinic for more 6 months and diagnosed to have degenerative lumbar spine disease.

Each participant filled a 25 point survey and a total of 105 surveys were collected.

Results: Out of the 79% who had access to the internet, 55% accessed it from home which is in comparison to the national statistics of 57%. The rest of 24% access internet at other places. Internet usage was found to be directly proportional to education and earnings with 100% in professionals and then dropping significantly. 80% living in urban areas used internet to access health information. Topics commonly searched include causes (74%), symptoms (70%), treatment/surgical options (82%). Only few people looked at the choice of surgeons (30%) and hospitals (30%) as the practice is mostly NHS based. Around 50% made clinical decisions based on their search. 86% used general search engines like yahoo, google, 14% used sites like med line, NHS. UK. Health professionals had more influence in decision making than internet (80%).

Conclusions: Internet is evolving as a powerful source of health information and influencing more an more patients in clinical decision making with a 5% growth in internet usage every year (national statistics).

Background: Lumbar disc replacement is a good alternative to fusion in young patients with degenerative disc disease or discogenic back pain. Despite the increase in the use of anterior lumbar disc replacement, there has been little published data of the specific types and frequencies of the complications associated with its use.

Aims & Methods: Purpose of the study is to retrospectively study the perioperative complications associated with CHARITÉ® Artificial Disc replacement. The lumbar spine is retroperitoneally approached, viscera and major vessels retracted and the disc replaced. We reviewed the operative and hospital records of 54 charite disc replacements done by the senior author from 2004 till September 2006.

Results: The study group had 23 men and 31 women with a mean age of 38 years (range 31–47). Preoperative diagnosis was degenerative disc disease in 42 patients (78%); discogenic back pain in 12 patients (22%). The most common level replaced was L4/5 (48%) followed by L5/S1 (35%). The most common complication during the procedure was venous injury involving one of the left iliac vein tributary (9 patients, 16%). There was no arterial injury. The median blood loss was 450ml (100–1500ml). There was peritoneum breach in six patients, but no case of bowel, ureter, and bladder or kidney injury. There were two incidences of significant post operative ileus and one developed S1 radiculopathy from lateral disc placement. One developed incisional hernia and two patients had to be revised to fusion. Retrograde ejaculation was reported in 3 patients. No incidence of epidural vein bleed, CSF leak, infection, paraplegia or death.

Conclusions: Anterior spinal surgery is a relatively safe procedure with a lower complication rate than was previously reported. Vascular injury was the most frequent complication. The incidence of autonomous dysfunction affecting pelvic floor function appears to be under-estimated and needs further study.

Background: The Wallis Interspinous implant was developed as a minimally invasive and anatomically conserving procedure without recourse to rigid fusion procedures. The initial finite element analysis and cadaver biomechanical studies showed that the Wallis ligament improves stability in the degenerate lumbar motion segment. Unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels allowing for the potential of the disc to repair itself.

Aims & Methods: The purpose of this prospective study is to demonstrate the survivorship and clinical effectiveness of Wallis implant against low back pain and functional disability in patients with degenerative lumbar spine disease. Patients were assessed pre operatively and post operatively every 6 months by VAS pain score, Oswestry Disability Index, SF-36. All the patients had pre operative radiographs, MRI scans and followed up with interval radiographs. The results were assessed in three sub groups. Group-1 is decompression and stabilisation, group-2 is stabilisation alone, and group- 3 is “Topping off” a fusion.

Results: A total of 211 Wallis Ligaments were inserted in 203 patients between July 2003 and November 2006. In total 179 patients were reviewed with mean age of 54(24–85) were followed for an average 30 months (6–40). The most common level is L4/5 (59%) followed by L3/4. In all the subgroups pain scores and oswestry disability index improved by 50%. And similarly SF-36 scores improved. There is 75–80% good clinical outcome with a survivorship of 98–99%.

Low infection rate of 1.1%. Two cases of prolapsed discs at the same level requiring further discectomy and one case of iatrogenic L4 paraesthesia.

Conclusions: The Wallis ligament represents a successful non fusion alternative in treatment of degenerative lumbar spine disease with least soft tissue damage, quick rehabilitation, less morbidity and associated low complication rate.

The Wallis implant treats pain, preserves mobility, anatomy and stability while being fully reversible, therefore leaving all subsequent options open.

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.

Background: Retrograde ejaculation has been reported to range from 2% to 16% following anterior surgical approaches to lower lumbar spine, but the exact incidence is not known. It has been felt for sometime that transecting or extensive dissection of the hypogastric plexus about the lumbo sacral junction could interrupt the sympathetic control of urogenital system and interfere with sexual function.

Invasive tests such as urodynamic tests, anorectal manometry and post ejaculatory urine sample would precisely determine its incidence. As a first step we, along with Urogynaecologist devised and validated a questionnaire to determine the urogenital function post operatively.

Aims & Methods: To retrospectively determine the incidence of sympathetic dysfunction in anterior lumbar spine surgery. 46 of 60 patients (76% response) who had anterior lumbar spinal surgery answered a validated questionnaire with urinary and bowel function, International Index of Erectile Function (IIEF) for men and Female Sexual Function Index (FSFI).

Results: All the females post operatively had retained bowel function and there were no reported cases of sense of urgency, incontinence of stools or flatus. But only one patient reported urinary stress incontinence. There was no change of sexual function as concluded from FSFI score.

In males we had 3 cases of retrograde ejaculation which affected the sexual function (based on IIEF score), and were reported to be resolving slowly. There was no incidence of any urinary or bowel dysfunction postoperatively.

Conclusions: This retrospective study only showed the overall picture of the incidence of pelvic floor dysfunction following anterior spinal surgery. A prospective trial is underway to determine its incidence.

Background: The major problem achieving lumbar spinal fusion is developing pseudarthrosis. At present the gold standard in achieving fusion is the use of autograft from pelvis or posterior elements of the spine. However the potential limitations of insuffient quantity and donor site morbidity have led to search for bone graft alternatives like DBM which contains osteinductive BMPs.

Aims & Methods: A Prospective Randomized Control trial comparing the effectiveness of demineralised Bone Matrix (DBM Putty)/autograft composite with autograft in lumbar spinal fusion.

35 patients were included in the trial; they were randomized to have DBM and autograft on one side, and autograft alone on other side to side. Patients were followed up with interval radiographs for total of 24mons. To date 20 patients have completed minimum 12mons follow up. The mineralization of fusion mass lateral to the instrumentation on each side was graded Absent, Mild (< 50%), Moderate (> 50%) or Complete fusion (100%). The assessment was made by two orthopaedic consultants and a musculoskeletal radiologist who were blinded to graft assignment.

Results: The sex distribution was 11:9 male to females with a mean age of 55.2 (21–87 years) and an average follow up of 18mons (12–24mons). Nine patients had single level fusion and the remainder had more than one level fusion. At 12 months on the side of DBM, 15% (6 of 20) had complete fusion, 80% (16 of 20) had moderate fusion, and 5% had no fusion mass. During the same period on the other side, 25% did not show any sign of fusion. There was no correlation with number of levels, age or sex.

Conclusions: Osteoinductive properties of DBM would appear to help in achieving early and higher union rates in lumbar spinal fusion. DBM reduces the amount of harvested autograft graft and also minimises the morbidity of donor site complications.

Purpose of Study: To prospectively study the clinical and radiological outcomes following lumbar interbody fusion with an intersegmental device(SpineLink™, Biomet) in smokers versus non smokers.

Materials and Methods: 64 patients who underwent spine fusion with intrasegmental fixation were prospectively studied at Mayday University Hospital. 54 patients with suffient follow up were included. Patients were assessed pre and postoperatively clinically using validated scoring systems (VAS pain score, SF-36 v1, Oswestry Disability Index). Radiologically classified into fused, indeterminate or pseudoarthrosis.

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.