Minimal clinically important differences (MCID)
in the scores of patient-reported outcome measures allow clinicians to
assess the outcome of intervention from the perspective of the patient.
There has been significant variation in their absolute values in
previous publications and a lack of consistency in their calculation. The purpose of this study was first, to establish whether these
values, following spinal surgery, vary depending on the surgical
intervention and their method of calculation and secondly, to assess
whether there is any correlation between the two external anchors
most frequently used to calculate the MCID. We carried out a retrospective analysis of prospectively gathered
data of adult patients who underwent elective spinal surgery between
1994 and 2009. A total of 244 patients were included. There were
125 men and 119 women with a mean age of 54 years (16 to 84); the
mean follow-up was 62 months (6 to 199) The MCID was calculated
using three previously published methods. Our results show that the value of the MCID varies considerably
with the operation and its method of calculation. There was good
correlation between the two external anchors. The global outcome
tool correlated significantly better. We conclude that consensus needs to be reached on the best method
of calculating the MCID. This then needs to be defined for each
spinal procedure. Using a blanket value for the MCID for all spinal
procedures should be avoided. Cite this article:
The introduction of novel systems for correction of scoliosis should be subject to critical analysis and based on patient benefit. Retrospective analysis of prospective data from a single surgeon consecutive series of Lenke 1 type curves. The two cohorts compared K2M and AOUSS2. Pre and Post operation Cobb angle, flexibility, absolute correction rate, implant related correction, levels fused, implant density, implant cost and cost per Cobb improvement analysis were collected.Aim:
Methods:
There has been a recent surge in the interest of the role of vitamin D in chronic musculoskeletal pain however there are limited studies that have investigated the link of vitamin D hypovitaminosis with low back pain. The aim of our study was to determine the prevalence of low vitamin D levels in patients who present with low back pain in an outpatient setting in the UK. Data was collected retrospectively from computerised databases of all patients who presented with low back pain from a single spinal consultant's outpatient clinic and have had serum levels of 25-hydroxycholecalciferol (25-OH vitamin D) requested. Data of these patients were collected from hospital electronic and paper records and analysed against their serum 25-OH vitamin D levels.Introduction
Methods
Yellow flags are psychosocial indicators which are associated with a greater likelihood of progression to persistent pain and disability and are referred to as obstacles to recovery. It is not known how effective clinicians are in detecting them. Our objective was to determine if clinicians were able to detect them in secondary care. 111 new referrals in a specialist spine clinic completed the Oswestry Disability Index (ODI) and a range of other validated questionnaires including the yellow flag questionnaire adapted from the psychosocial flags framework. Clinicians blinded to the patient data completed a standardized form to determine which and how many yellow flags they had identified.Introduction
Methods
The outcome of surgery for recurrent lumbar disc
herniation is debatable. Some studies show results that are comparable
with those of primary discectomy, whereas others report worse outcomes.
The purpose of this study was to compare the outcome of revision
lumbar discectomy with that of primary discectomy in the same cohort
of patients who had both the primary and the recurrent herniation
at the same level and side. A retrospective analysis of prospectively gathered data was undertaken
in 30 patients who had undergone both primary and revision surgery
for late recurrent lumbar disc herniation. The outcome measures
used were visual analogue scales for lower limb (VAL) and back (VAB)
pain and the Oswestry Disability Index (ODI). There was a significant improvement in the mean VAL and ODI scores
(both p <
0.001) after primary discectomy. Revision surgery also
resulted in improvements in the mean VAL (p <
0.001), VAB (p
= 0.030) and ODI scores (p <
0.001). The changes were similar
in the two groups (all p >
0.05). Revision discectomy can give results that are as good as those
seen after primary surgery. Cite this article:
The majority of studies assessing minimal clinical important difference in outcome do so for management of chronic low back pain. Those that identify MCID following spinal surgical intervention fail to differentiate between the different pathologies and treatments or use variable methods and anchors in the calculation. To identify the MCID in scores across the most common spinal surgical procedures using standardised methods of calculation.Background
Aim
In 2009, NICE CG 88 guideline on the management of non-specific low back pain was published. We looked at whether the introduction of these guidelines has had an impact on the management of back pain within primary care. Patients with non-specific low back pain (> 6 weeks but < 12 months) attending spinal outpatient clinic in UHL between 2008 and 2011 were asked to complete questionnaires. Two groups were studied, the first prior to the publication of NICE guidelines, and the second afterwards. Patients with radicular, stenotic and red flag symptoms were excluded. Key audited treatment standards assessed included manual therapy, acupuncture, focused structured back exercise program, supervised group exercise program and lastly referral to a combined physical and psychological treatment program. Compliance with not using X-ray or MRI and treatment modalities such as injections, laser therapy, ultrasound therapy, lumbar supports, traction and TENS therapy was assessed. Secondary outcomes included VAS (back, leg pain), Oswestry Disability Index, MSP and MZD. Primary outcomes analyzed using 1-sided Fisher's exact test and secondary outcomes using two sample t tests.Background
Methods
In all traumatic injury there is a clear relationship between the structural tissue damage and resultant disability after recovery. There are no publications that compare significant thoracolumbar osseous injury to non specific soft tissue injury. To compare spinal outcome measures between patients with self reported back pain in the workplace perceived as injury to those having sustained structural injury in the form of an unstable thoracolumbar fracture requiring surgical stabilisation.Introduction
Aim
It is not known how parents of children with scoliosis perceive cosmetic issues in their offspring. There is little clinical information regarding parental 'surrogate' assessment of a young persons' fears and beliefs regarding how a deformity affects the child and how that might influence the process of informed consent and surgical risk assessment. Patients and their parents had a structured interview involving SRS20 and Walter Reed Visual Assessment Scale. The parents were asked to complete an SRS20 as they expected their child to complete it. That is they were asked to anticipate how the child might score and grade the SRS 20. 28 patients, 6 males, 22 females, 8 females were pre-menarche, mean age 14 (12-17), mean cobb angle 57, completed the study. Mean parental age 45. There were 6 fathers and 22 mothers. The mean SRS scores for the domains for children were pain 2.49, self image 2.3 function 2.9 Mental health 2.9 Total 10.7. The mean SRS scores for the domains for the parents were pain 2.38 self image 2.39 function 2.97 Mental health 2.87 Total 10.5 There was no significant difference between mean scores for the four domains of the SRS20Method
Results
To identify a means to reduce the duration and radiation dose coupled with fluoroscopic guided nerve root blocks (NRB). Consecutive prospective two cohort comparative study. A similar method performed during CT guided NRBs was employed to guide needle placement for transforaminal nerve root injections with the aid of static MR images and fluoroscopy. Axial MR images at the level of the target nerve root were used. An angle of inclination of 60 degrees was created from the nerve root to the skin of the back, the apex of this to represent the site of needle introduction. Triangulation on the MRI enabled the lateral entry point to be determined. The transforaminal injections were then performed with the simple expedient of a skin marker line at the appropriate lateral distance from the midline for needle entry. The radiation dose and fluoroscopic time as measured by the image intensifier were recorded. This method was performed for 20 patients and compared to the same parameters for 23 previous patients in whom the transforaminal injections were performed without such a technique.Aim
Method
To compare outcomes of revision lumbar discectomy to primary surgery in the same patient cohort. Prospective outcome data in 36 patients who underwent primary and subsequent revision surgery for lumbar disc herniation between 1995 and 2009. Outcome measures used were Visual Analogue Scores for back (VAB) and leg pain (VAL), the Oswestry Disability Index (ODI) and Low Back Outcome Score (LBO). 5 early recurrences within 3 months were excluded.Aim
Methods
Thoracolumbar fractures are the most common spinal injuries resulting from blunt trauma. Missed spinal injuries can have serious consequences. Our objectives were to determine the utility of trauma series chest and abdomen computed tomographs for detecting clinically unrecognised vertebral fractures and to analyse those missed on clinical examination. The aim was to identify an ‘at-risk’ patient group with negative clinical examination warranting evaluation with CT screening.Background
Objective
To compare spinal outcome measures between patients reviewed for medico-legal compensation claims relating to perceived injury at work to those having sustained serious structural injury in the form of unstable thoraco-lumbar fractures requiring internal fixation. Two consecutive cohorts of 23 patients with healed spinal fractures and 21 patients with a perception of work related soft tissue injury were compared. Patient demographics and a range of outcome measures including Oswestry Disability Index (ODI), Low Back Outcome score (LBOS), Modified Somatic Perception (MSP) and Modified Zung Depression (MZD) indices were measured.Aim
Method
To prospectively determine the relationship between the two most commonly used generic spinal outcome measures, the Oswestry Disability Index (ODI) and the Low Back Outcome Score (LBOS). Outcome measures inform audit and research. Few spine surgical specific outcome measures are in general use. Generic measures are used for a variety of spinal disorders it is not known which is best or exactly how they relate for different conditions. Pre-operatively and two years post surgical results were available in 240 patients. There were 125 males, 115 females. Sub groups numbering 82 discetomy, 78 decompression, 26 revision and 19 fusions were analysed. Average age 55 years (range 23-88). The pre op average ODI was 55% and the LBOS was 29. Correlation was -0.73. The overall post operative score at 2 years was 34% ODI and 37 LBOS, the correlation was better at -0.87. The correlation between the two scores post operatively was very good for Discectomy surgery (-0.916) and fusion surgery (-0.907) but not so close pre operatively with Discectomy (-0.786) and fusion correlation poor at (-0.302). Revision surgery and decompression surgery had similar good correlation post operatively. The correlation of both outcome measures to the Modified Zung depression index was poor. The poor pre operative correlation suggests that thresholds for surgery cannot be compared within registries using different measures. The post operative scores and change in scores correlate better. This is important in comparative studies using different outcomes scores within the same spine registry. No conflict of Interest. Registered database and audit of service standard
Clinical and radiological indicators of outcome in the use of X-Stops were sought by evaluating patient-centred outcomes alongside radiographic scrutiny of changes around implants with correlation to outcome. Prospectively collated outcome scores were correlated to outcome, with retrospective analysis of pre-operative MRI scans and 117 post-operative radiographs. Single surgeon series of 44 patients(52 implants). Clinical - ODI, walking distance, Low Back Outcome Score, MZDI and MSP. Radiographic - lucency(anterior and cranio-caudal to implant), coronal rotation, dorsal migration of implant. Failure defined by persistent symptoms requiring removal+/−decompression. Pre-operative features of success: lower ODI(p<0.05), higher LBOS(p<0.01), higher walking distance(p<0.01), lower MZDI(p<0.01). Marked differences were noted in post-operative scores for the two cohorts. An eight-fold improvement in walking distance in success patients compared to an increase to 1.8 times the baseline in failures. ODI improved ten times more in the success group at 20 cf2(failure). MZDI improvement was greater in the revisions at 2.2 cf 0.9 in successes. Ranking Pearson's coefficient of radiograph measurements in success and failure cohorts, revealed failure associated most to anterior lucency(R=0.93), rotation(R=-0.61), cranio-caudal lucency (R=-0.29) and migration (R=-0.25). Success most associated to rotation (R=-0.22). Failure radiographs revealed greater lucency cranio-caudal and ventral to the implant, more coronal rotation, and pronounced dorsal migration. Clinical features of success are older patients with no co-morbidities, unilateral leg pain and multi-level insertion. Males, those with bilateral leg pain, and scoliosis or spondylolistheses are more likely to fail.
The use of interspinous distraction devices should remain the subject of audit and research. They are a relatively new addition to the armamentarium of surgical treatment of lumbar spinal stenosis. The reported results are variable and there are a number of different devices available. It is recognised that there is an early failure rate with interspinous distraction devices. This is a report of the clinical results after conversion to segmental lumbar decompression following a failure of interspinous distraction procedure. 18 patients had removal of device and conversion to a standard lumbar decompression at an average of 13 months after the index procedure. There were 7 females and 11 males. The average age was 68 years (range 49-85). The two youngest patients had a decompression and instrumented fusion, the others had decompression alone. Prior to the Index procedure of stand alone interspinous distraction device the average Oswestry Disability Index (ODI) was 42 and Visual Analogue Score (VAS) leg 7.2. Prior to revision the average ODI was 42 and VAS leg 6.7. Complications: One intra operative myocardial infarction, one incidental durotomy and one post operative infection (pseudomonas isolated). At a mean of 9 months follow up the average ODI was 23 and VAS leg 2.1. The VAS back was 1.9. The walking distance was subjectively reported as 246 yards pre op and 1100 yards post procedure. There was a clinically significant improvement in all patients. A failed interspinous distraction device can be satisfactorily salvaged with a segmental lumbar decompression.
Comparison of clinical, radiological & functional outcomes of corrective surgery for right thoracic AIS curves. There is a paucity of data relating functional outcomes to the radiological and surface measurement results of either posterior or anterior surgery for right thoracic AIS. Prospective, cohort study, mean follow up 35 months (range 9-115) 38 patients (6 males); 22 Lenke 2 posterior, 16 Lenke 1 anterior. Primary= rib hump, radiological (frontal Cobb correction, apical vertebral translation AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI). Secondary= estimated blood loss (EBL), operative time, complications No significant difference at P<0.005 with student t-test unless indicated Rib Hump: 16° posterior 17 ° anterior, corrected to 8 ° (50%) and 6 ° (60%) respectively. Thoracic Cobb: 70° posterior 61 ° anterior, corrected to 27° (61%) and 22° (64%) respectively. No difference in preoperative curve flexibility or fulcrum bending correction index. Thoracic AVT 55% correction posterior, 70% anterior, Lumbar Cobb 59% correction posterior, 52% anterior. Thoracic kyphosis significantly reduced in posterior surgery (35 ° to 20 °) and significantly increased with anterior surgery (21° to 30°). Lumbar lordosis significantly reduced with posterior surgery (88° to 47°), no significant change with anterior surgery (60° to 53°). MSRSI; Domain scores similar preoperatively between groups. Difference scores (postop-preop), higher scores=better. Pain: +1.21 posterior +0.73 anterior. Self image: +1.02 posterior +0.71 anterior. Function/activity: +0.28 posterior +0.21 anterior. Mental health: +0.66 posterior +0.45 anterior. No significant difference in complication rate, operative time or estimated blood loss Similar cohorts of AIS patients treated by either anterior or posterior surgery have no significant differences in radiological or functional outcomes. The different final sagittal profile in both groups did not affect the MSRSI outcomes. Both procedures deliver significant health gains as measured by the MSRSI.
Establish the prevalence of B12 deficiency in patients presenting for surgical assessment and to audit subsequent management. Retrospective: The pathology database was interrogated for all B12 and folate requests under the name of a Spine sub-specialty Consultant over a four year period (2005-2008). 38 patients with B12 deficiency were identified. Patient self reported symptoms, drug history, Global outcome score (Much better, better, same, worse) Visual Analogue Score (VAS) and Oswestry Disability Index(ODI). 458 tests occurred. 38(8.3%) were B12 deficient. Of these, 10 (26%) had received no treatment at review. Average age 63 years. 23 males, 15 females. 6 patients were diabetic. At clinic attendance Mean ODI 46%; VAS(leg) 6.4. A sample from those with a normal B12 had ODI 45%; VAS(leg) of 5.9. Of the three who were “worse”, one had been treated. 7 of the 12 patients who felt the “same” had received injections. 9 were “better” with 5 on supplements. Five were “much better” with all patients on supplements. Less than half(47%) were prescribed analgesia, 11 out of 38 were taking paracetamol, 6 were prescribed NSAIDs, 6 opiates, and 10 were taking neuropathic painkillers. Reversible causes of neuropathic pain can only be identified by testing. A high index of suspicion resulted in positive tests in 8% of the population studied. Administrative obstacles exist to treatment. Those that are treated do better. Sensory symptoms in a spine clinic patient should not be assumed to originate exclusively from the spine. Audit/service standard registered in Trust No conflict of interest
To determine the factors that influences the clinical outcomes in surgical correction of thoracic AIS. There are conflicting data regarding the effects of back shape and radiologic parameters on the self-reported outcomes of surgery in AIS. Prospective, cohort study; mean follow-up 29 months (range 9-88) 30 patients (5 males); Rib hump 17 ° corrected to 7 °. Thoracic Cobb 66 ° corrected to 25 ° (63%). Lumbar Cobb 42 ° corrected to 17°. Thoracic apical vertebral translation (AVT) 48mm corrected to 18mm. Lumbar AVT 34mm corrected to 19mm. Thoracic kyphosis 29° preoperatively 23° postoperatively. Lumbo-sacral lordosis 57° preoperatively 49° postoperatively Modified SRS Outcomes Instrument (MSRSI) filled out pre-operatively and at final follow up. Primary= rib hump, radiological (frontal Cobb correction, lumbar & thoracic AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI) domain scores. The magnitude of the rib hump had a significant association with pain: Rib hump vs. MSRSI pain r= -0.55 p<0.000 Similar correlations existed between rib hump and self-image (r=-0.64, p<0.0000), thoracic Cobb angle with pain (r=-0.48 p<0.0001) and self-image (r= -0.57, P<0.0000). The postoperative thoracic Cobb angle, and percentage thoracic Cobb correction had significant correlations with self-image (r=-0.55 p=0.003 & r=0.54 p0.004 respectively). The size of the rib hump has a significant impact on pain & self-image. These domains are also significantly influenced by the residual thoracic Cobb angle and overall scoliosis correction.
There remains debate regarding which surgical approach gives the best outcome, anterior alone or posterior alone, in surgically relevant adolescent idiopathic scoliosis. The operation is mainly cosmetic in terms of health care advantage. This prospective study evaluated scar site preference and other relevant body image parameters prior to any intervention. Patients and their parents had a structured interview involving SRS20 and Walter Reed Visual Assessment Scale as well as grading of nine AP and lateral clinical photographs specifically of anterior and posterior scoliosis surgery scars. Each clinical image was graded 1-10 on a scale of unsatisfactory and satisfactory. Parents completed assessments as well as the patients. Results: 28 patients, 6 males, 22 females, 8 females were pre-menarche, mean age 14 (12-17), mean cobb angle 57, completed the study. Mean parental age 45. There was no significant difference between mean scores for the four anterior scar (6.36) and the five posterior scar (6.35) images. p value 0.49. In parents the preferences were more apparent posterior 6.9, anterior 6.2 but this was not statistically significant (p=0.06) There was no significant difference between all four domains of the SRS between parent and child. In terms of expressed preference the child had no preference in 7, thoracotomy in 7 and posterior midline in 14, whereas parents expressed no preference in 12, thoracotomy in 4 and posterior midline in 12. In this prospective study there was no perceived difference in acceptability of anterior or posterior scars for scoliosis surgery approaches.
