We describe the results of a prospective case series to evaluate a technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a u-shaped modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation. 20 patients aged between 9 and 21 years with a pars defect at L5 confirmed on computed tomography (CT) were included. The average age of the patients was 13.9 years. The eligible patient had Grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The average duration of follow-up was 4 years. Clinical assessments for all patients was via the Oswestry disability index (ODI) and visual analogue scores (VAS). At the latest follow-up, 18 of the 20 patients had excellent clinical outcomes with a significant (p<0.001) improvement in their ODI and VAS scores with a mean post-operative ODI score of 8%. Fusion of the pars defect as assessed by CT showed fusion rates of 80%. There were no hardware complications. The strength of the construct obviates the need for post-operative immobilisation.

Backpain is a common cause of patient referral to pain clinics. Around 120 000 patients with back pain are seen in UK Pain Clinics every year. Facet joint injections are a commonly used treatment modality. However there is considerable controversy regarding their efficacy. Most of the evidence supporting the use of injections is anecdotal, rather than being based on randomised studies.

We carried out a prospective study to assess the efficacy of facet joint injections in relieving chronic low back pain. Our study group comprised 41 patients (57% females, 43% males). Patients completed the Oswestry Disability Index (ODI) and marked their pain levels on a Visual Analogue Scale (1 to 10).

We found that though the pain score improved from 6.9 to 4.3, there was only a marginal improvement in the ODI from 52.5 to 50.8. Overall 85 % of patients experienced some improvement, while 15% felt their symptoms had worsened after the injections. One of the most significant findings of this study was the fact that the improvement in most patients lasted only for an average of three weeks. This is significantly less than most previous studies indicate. Interestingly, inspite of this limited improvement, almost all patients expressed the desire to be placed back on the list for repeat injections.

Our study demonstrated a beneficial short term effect of facet joint injections. In our opinion, they are a reasonable adjunct to non operative treatment of chronic backpain.

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation.

The strength of the construct removes the need for post-operative immobilisation.

Introduction: Schober’s test, along with the modified version have long been used to assess lumbar flexion. The modified Schobers test, as described by McRae et al, is now the more commonly used. Both these tests rely on the assumption that movement of skin over the lumbar spine represents the degree of lumbar spine flexion. To our knowledge neither of these tests have been validated. Our aim is to validate the modified Schobers test as a method for measuring lumbar flexion.

Materials and Methods: Our inclusion criteria were:

normal subjects with no known structural abnormalities in spine or pelvis.

Accurate measurement of lumbar spine flexion is possible using a machine made by a Finnish company called Data Based Care (DBC). The machines accurately measure ranges of spine movement by isolating the movement being measured and immobilising any other muscle groups which may interfere with the movement being measured.

We measured lumbar spine flexion as described by Mc Rae et al ie. The modified Schobers test and isolated lumbar spine flexion using the DBC machine.

Two researchers were involved in measuring subjects. One set the subject on the DBC machine and took the measurement, whilst the other assessed when the pelvis began to tilt. Thus only isolated forward lumbar flexion was measured. DBC measurements were carried out in a standardised way. The results were then tabulated and correlated.

Results: Our study included 100 people of whom 54 were male and 46 female. Average age was 38. The median measurements for modified schober’s test and DBC were 5 and 44 cm respectively. The measurements of both modified schober’s test and actual lumbar flexion using DBC were correlated with spearman’s rank correlation test showed no correlation.

Conclusion: Our results show no correlation at all between the actual range of lumbar flexion and the modified Schobers test. We state that this test is invalid and its place in clinical practice unjustified.

Introduction: Tuberculosis (TB) continues to cause a significant burden of disease in the United Kingdom (UK). A total of 8113 cases were diagnosed in England, Wales and Northern Ireland in 2005, demonstrating a 28% increase since 2000. The incidence of TB in London is four times greater than the national average, with 43% of cases of TB in 2005 being identified in the capital (n= 3,479). 47% of TB cases in the UK have extra pulmonary involvement and 2–3% of all cases of TB involve the spine (n= 107)

Methods: We reviewed 109 patients treated for spinal TB in East London, UK, between 1997–2006. 59 were male and 50 were female. Their mean age was 39 (range 4–89). 63 patients were Asian (3 UK born), 30 African, 8 UK born Caucasian, 4 Caribbean (1 UK born), 3 patients from Eastern Europe and 1 from the Middle East. Of those patients born outside the UK, the mean time they had been in the country pre diagnosis was 9.6 years (range 0–50 years). They were followed up for a minimum of 1 year post completion of treatment (range 14 to 48 months).

95% of patients presented with back pain, with or without neurological compromise.

All patients were imaged with MRI or CT. 90 (86%) patients had microbiological and/or histological confirmation of TB. The majority of patients (52%) had two vertebral levels affected. The Thorocolumbar junction was the area most commonly affected. 4% of patients had paravertebral abscesses with no bony involvement seen on imaging. 29 patients (26%) had associated psoas abscess.

Combination chemotherapy, according to NICE guidelines, was the main modality of treatment. 67 (61%) patients were managed with combination chemotherapy alone. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 42(39%) of patients required surgery.

Results: There were no deaths related to TB or our intervention. Most patients had a full neurological recovery but 21 patients (19%) suffered permanent neurological deficit. (4%) suffered permanent paraplegia or paraparesis severe enough to prevent walking.(out of this anybody had surgery and if so how delayed was that) There was a high incidence of persistent chronic back pain (62%) in our group of patients and was not related to any deformity.

Conclusion: Medical management is the mainstay of treatment for spinal TB, but there are certain instances where surgical intervention will be required.

Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients we set up dedicated multidisciplinary spinal TB clinic and are managed jointly by respiratory and orthopaedic teams.

Background: Tuberculosis continues to increase in England, Wales and Northern Ireland. The London region accounted for a substantial proportion of cases in 2005 (43%) and had the highest rate of disease (46.3 per 100,000). Skeleton is a common site of predilection. However, diagnostic evaluation of vertebral TB is hampered by the difficulty of MRI interpretation and failing to keep a high index of suspicion.

Methods: Cross sectional sampling of all patients with confirmed vertebral TB between the years of 1999–2006 in two large London hospitals covering; Royal London Hospital and King George Hospital. Various dermographic parameters were evaluated. The mode of presentation, surgical procedures and outcome of patients were highlighted.

Results: One hundred and twenty three patients were identified with a Mean age of thirty four years. Male and female was 55%, 45% respectively. Asians represent the highest immigrant group followed by Afrocarbian at 63%, 28% respectively. White British represents only 6.5%. The dorsal spine was the most commonly affected site at 45%, then lumbar spine in 33% followed by multiple regions in 11%. Delayed diagnosis was made in 34% of patients, 44% of them over six months.

Back pain/neck pain was the presenting complaint in 100% whereas neurological signs were found in 37% and systemic manifestations present in 38%. To control the disease, spinal surgical procedures was needed in 44% of cases. Approximately 30% of them had partial recovery and 9% had complete recovery.

Conclusions: The incidence of vertebral TB is on the increase. A high index of suspecion is required to avoid delay in the diagnosis. Knowledge of the patients’ background may help making approperiate early referral for MRI especially among Asian groups.

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.

Introduction: Tuberculosis (TB) continues to cause a sig-nificant burden of disease in the United Kingdom (UK). The incidence of TB in London is four times greater than the national average, with almost half of the 7000 cases/year seen nationwide being found in the capital. Although the majority of cases are pulmonary, extra-pulmonary infection is not uncommon.

Methods: We reviewed 107 patients treated for spinal TB in East London, UK, between 1997–2006. 59 were male and 48 were female. Their mean age was 39.9 (6–89). 69 patients were Asian, 26 African, 10 UK-born Caucasian, 1 other European and 1 Middle Eastern. Rates of HIV co-infection are inexact as many declined to be tested.

All patients presented with symptomatic back pain, with or without neurological compromise.

All patients had appropriate pre and post treatment imaging. 100 had microbiological and/or histological confirmation of TB. The disease was predominantly in the thoraco-lumbar spine, although cervical involvement was seen in 5%. All patients presented with anterior column involvement, with psoas abscesses in 30%.

Combination chemotherapy, according to British Thoracic Society guidelines, was the main modality of treatment. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 15% of the 107 patients treated required surgical intervention.

Results: There were no deaths related to TB or our intervention. Most patients had full neurological recovery, but a small percent had permanent neurological compromise. There was a high incidence of persistent chronic back pain for which patients continued to seek medical advice.

Conclusion: Medical management is the mainstay of treatment for spinal TB, but there are certain circumstances where surgical intervention will be required. Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients, 2 years ago we set up what we believe to be the only dedicated multidisciplinary spinal TB clinic in the UK. Patients are managed jointly by the respiratory and orthopaedic teams.

Introduction: This study highlights the occurrence of significant post operative scoliosis associated with en-bloc resection of pancoast or superior sulcus tumours. We observed the rapid onset of high thoracic scoliosis following en-bloc resections. The Magnitude of the scoliosis, and predisposing surgical factors were reviewed in each of the cases implicating the role of the transverse process or its associated structures in the stabilization of the spine.

Methods: Sixteen patients undergoing en-bloc resection for pancoast tumour were retrospectively reviewed. This was a single surgeon series where all patients had tumour resection over a 3 year period. The number of upper ribs and transverse processes resected were analysed and compared with the magnitude of scoliosis that developed over a follow up period of 2 years.

Results: Four patients had significant resection of the transverse processes of T1 to T3. All of these patients developed scoliosis of rapid onset, convex to the side of the resection. Of the remaining 12 patients either no scoliosis developed, (6 of 12), or scoliosis of less than 12 degrees.

Discussion: We observed rapid development of thoracogenic scoliosis in patients following lung tumour and chest wall resection. Our study shows that excision of the transverse processes is associated with subsequent development of an upper thoracic scoliosis. Preservation of the transverse process appears to be protective. Large resections can be performed with no subsequent scoliosis provided the transverse processes remain intact.

This suggests that the transverse process or its associated structures have an important stabilizing function on the spine.

Introduction: Postoperative overdistention of the bladder produces chronic, irreversible changes in the detrusor muscle. This study investigated whether an effective epidural, may cause postoperative overdistention of the bladder.

Methods: A retrospective single surgeon/unit study of 144 male patients who had undergone spinal surgery over a two year period was undertaken. Data was collected into two groups: Patients requiring catheterisation and those that did not. All patients received a 16G epidural catheter inserted at the end of the procedure.

Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded.

Results: Patients remained on postoperative epidural analgesia for an average of 50hours. 54 patients required urinary catheterisation. The average postoperative duration until catheterisation was 18hours, with a maximum of 33hours.

The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding.

Discussion: Although patients in the catheterised group were older, (p< 0.05), we found no other significant differences in patients that subsequently required catheterisation, when compared for operation type, or epidural infusion rates.

We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention.

Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit.

Study Design: Prospective study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was developed as an intermediate stage between conservative measures (analgesia, physiotherapy and injections) and radical surgery (fusion and disc replacement) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this treatment.

Objective: To assess the long-term outcome of patients with discogenic low back pain (≥ 6 months duration) treated with IDET who had previously failed to improve with nonoperative treatment

Methods: Forty patients with IDD determined by pre-operative provocative discography and MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. The differences in the outcome scores were tested by Wilcoxon signed rank tests.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. No significant improvement was seen in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscales. Only 11% used less pain medication. Sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery; 5 disc replacement and 3 fusions at 1-year post treatment.

Conclusion: The patients with IDD did not show any improvement at 1-year or 2-year post IDET. A significant proportion of patients required further surgery. We believe that the efficacy of IDET is doubtful.

Study Design: Prospective longitudinal study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was introduced to bridge the gap between conservative measures (analgesia, physiotherapy and standard injection therapy) and radical surgery (disc replacement and fusion) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this so called less invasive treatment technology.

Objective: To assess the long-term outcome of patients with chronic discogenic low back pain (< 6 months duration) treated with IDET who had previously failed to improve with comprehensive nonoperative treatment.

Methods: Forty patients with IDD determined by provocative discography and pre-operative MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance times (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. Statistical analysis was performed using Wilcoxon signed rank tests to test for differences in the outcome parameter scores.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. The study group demonstrated no significant improvement in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscale scores at 0, 12 and 24 months after treatment. Analgesia requirement remained the same in 77% of the patients; 12% required stronger analgesia and only 11% used less pain medication. Although sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery in the form of a disc replacement or fusion at 1-year post treatment.

Conclusion: The patients with chronic discogenic low back pain in this study did not show any improvement at 1-year or 2-year post IDET treatment. A significant proportion of patients underwent further surgery for persisting low back pain. We believe that the efficacy of IDET in the treatment of chronic discogenic low back pain is doubtful.

We studied the various drill bits available for engineering purposes, and compared them with standard orthopaedic drill bits, using continuous temperature recording at 0.5 mm, 1.0 mm and 1.5 mm from the edge of a 2.5 mm hole as it was drilled in fresh cadaver human tibia.

We found that some commercially available drill bits performed better than their orthopaedic equivalents, producing significantly less thermal injury to the surrounding bone and halving the force required for cortical penetration. Our work suggests that the optimal bit for orthopaedic purposes should have a split point and a quick helix. Theoretical knowledge of cutting technology predicts that the addition of a parabolic flute will further reduce thermal damage. Further work is being done on other drill sizes used in orthopaedic practice and on new custom-designed bits.