Aims

Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF).

Use of ultrasonic bone scalpel (UBS) is becoming popular in spinal surgery. This study presents the safety profile of UBS for posterior release in surgical correction of adolescent idiopathic scoliosis (AIS).

From 2016 to 2018, UBS (Misonix) was used by the senior author in a variety of spinal operations. Data for intraoperative complications when this devise was used for posterior correction of AIS were collected. Revision cases were excluded.

UBS was used for posterior release of AIS in 65 patients (58 female, seven male) with an average age of 15.6 years (range 11–23). Average length of posterior instrumentation was 12 levels (range 6–14). Instrumentation was exclusively from T2 to L4. To achieve adequate release for correction, UBS was used to perform a total of 644 modified in-situ chevron osteotomies (average ten, range six to 12) and 31 rib osteotomies. Overall, three complications (4.6 %) were directly related to the use of UBS: one haemopneumothorax, which was successfully treated with a chest drain; and two loss of motor-evoked potentials during monitoring, which led to the postponement of the final correction. These two patients did not have any neurological problems and their surgery was completed successfully within 1 week of the initial surgery. One late deep infection was reported. This was not thought to be directly related to the use of UBS.

Use of UBS in the posterior surgical treatment of AIS appears to be relatively safe with a low level of acceptable complications. However, appropriate training is required for the use of UBS.

Background

Partial facetectomies with pedicle screw instrumentation is widespread and a well described technique for achieving posterior correction of scoliosis. Newton et al. first described the use of the UBS in the posterior correction of AIS in 2014. The aim of this study was to compare the effectiveness of the UBSPO in achieving posterior correction in Type1 AIS as compared to the traditional partial facetectomies. Aim of this study was to assess the effectiveness of USBPO in achieving posterior correction in Type 1 AIS as compared to partial facetectomies.

SUMMARY

A retrospective cohort study of 19 patients of EOS who underwent MCGR rod instrumentation with subsequent serial distractions, measured using ultrasonography. The degree of distraction achieved during each session were analyzed and subgroup analysis done.

Aim

We report our ten year experience of primary haematogenous non-tuberculous spinal infection.

Aim

To evaluate morbidity and outcome associated with lumbar spine decompression for central spinal stenosis in the elderly compared with younger age groups.

Background: Treatment of high-grade spondylolisthesis remains controversial. In-situ fusion does not address the sagital balance, reduction and fusion on the other hand is associated with unacceptably high rate of neurological complications.

Aim: To describe the results of a novel technique using Magerl External Fixateur for gradual reduction followed by circumferential fusion.

Methods: From 1988 to 2006, thirteen patients were treated with this technique at our institution. They all had high grade spondylolisthesis. Retrospective case note review and radiographic analysis were carried out. 10 point Visual Analogue Sore (VAS) for pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), SF-36 Health Survey, and Patient Satisfaction Questionnaire were collected. Complete set of data was available for 9 patients, 7 Female and 2 Male. Mean age at operation was 16 years (range 12–22), and average length of follow-up was 11 years (range 5–19)

Results: Post operatively, Percentage of Slip was improved by an average of 70%(range 32–96%)(p=0.001), Slip Angle by 72%(p=0.0001) and sacral Inclination by 59%(p=0.0016). Radiological fusion was achieved in all but one. VAS for leg and back pain improved from 8.4 (range 8–9) and 8.2 (range 6–10) to 0.8(range 0–2) and 1.2 (range 0–2) respectively. These improvements were statistically significant (p< 0.001). ODI at the latest follow-up averaged 8% (range 0–16%) and LBOS 56.6 (range 44–70). The mean SF-36 for physical domains was 87.5 (range 80–93) and that for the psychological domains was 91.25 (range 81–100). All patients were fully satisfied. 3 cases had culture negative excessive discharge from one pin site. 2 patients developed transient parasthesia and one patient developed asymptomatic pseudoarthrosis.

Conclusion: Our technique albeit in a small cohort of patients, achieved significant correction of the commonly used and widely accepted radiological measurements without any neurological complications. The radiological improvement was also reflected in statistically significant improvement in validated outcome measures.

Aim: To report our ten year experience of primary haematogenous spinal infection.

Method: Retrospective case note review of 42 patients presented to our unit with primary spinal infection between 1995–2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. Information with regard to Mobility, Domestic circumstances, Oswestry disability index(ODI), Hospital Anxiety and depression score(HAD), Visual Analogue Score (VAS) for pain and coping were obtained. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Mean age was 59.9 years (1–85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62%. Time from presentation to diagnosis averaged 19days (range 0–172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13–240). At mean follow up of 5.4 years (0.6–10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history(P=0.001), constitutional symptoms(p=0.001) and pyrexia at presentation(0.001) were positively associated with recurrence.

Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9).

Overall it was calculated that HIAS had saved a total of 940 in-patient days.

Conclusion: Primary spinal infection is a treatable condition. Disease and patient characteristics dictate the management strategy. Although most patients can regain their pre infection mobility and go back to their pre morbid domestic circumstances with little or no pain and psychological sequel, a proportion of patients end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection. Finally, HIAS was cost effective.

Aim: To evaluate morbidity and outcome associated with lumbar spine decompression for central spinal stenosis in the elderly compared with younger age groups.

Patients & Methods: Case notes review of patients with symptomatic and MRI proven central lumber canal stenosis, under the care of a single surgeon. The study population was 3 age groups: patients < 60 year of age (Group 1, n=19), patients between 61 and 79 years(Group 2, n=54), and > age of 80 years (Group 3, n=15).

The number of levels decompressed & grade of surgeon were noted.

Outcome data: Length of operation & hospital stay, blood loss, and intra and post operative complications. Subjective variables: Pain (VAS), walking distance, Oswestry Disability score (ODI) and patient satisfaction scores.

Results: The duration of operation (p< 0.05), and intra-operative complication rate (p< 0.025) was dependent on the seniority of the surgeon.

There was a statistically significant improvement in VAS score for leg pain (p< 0.05) and back pain (p< 0.05) after surgery for each group. The average walking distance improved by factor 5 in group 1 and 2 and by factor 2.5 in group 3 (p< 0.05)

Conclusions: Surgery for neurogenic claudication in the octogenarian is associated with a higher complication rate. The outcomes in this patient group is however comparable to younger patients.

Aim: In this study we present our ten year experience of primary spinal infection.

Method: Retrospective case note review of 42 patients who presented to our institution with primary spinal infection between 1995–2005 was carried out. Demographic data and information with regard to timing and modes of presentation, results of radiological and laboratory investigations, and methods of treatment were collected. The financial impact of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Axial pain was the most consistent symptom seen in 100% of the patients. Only 62% had pyrexia at presentation. Major neurological deficit was seen in 10.2%.

Mean duration of symptoms was 25 days (range 1–202). Mean time from presentation to diagnosis was 19 days (range 0–172). Staphylococcus Aureus was the most common organism. Mean duration of Intravenous antibiotics was 60 days (range 13–240) followed by oral antibiotics for mean duration of 65 days (range 0–161). CRP was more reliable in monitoring the disease over time. At mean follow up of 5.4 years (0.6–10.5) there has been no mortality directly related to the infection. With our management there has been 14% recurrence rate. All re- presenting within the first year after initial presentation (Mean 5.5 Months, range 1–11).

HIAS saved a total of 940 in-patient days with a total cost saving of approximately £350,000.00.

Conclusion: In the majority of patients spinal infection can be successfully treated. Disease severity dictates the duration of antibiotic treatment and whether surgery is required. Recurrent infection occurred in a number of patients with more significant past medical history and pre-existing risk factors. Finally, HIAS is extremely cost effective in this group of patients.

Aim: Retrospective review of patients after coccygectomy for post traumatic coccydynia.

Methods: 13 patients (2 male, 11 female; mean age 37.8 years) who had undergone coccygectomy in our unit between 1995–2005 were identified and their case notes were reviewed. All patients had coccydynia with clear history of trauma, had failed to respond to three MUA and injections, and on clinical examination by senior author had hypermobile coccyx.

All patients were operated by the senior author, using a standard technique whereby all segments of the coccyx from sacrococcygeal joint were excised. At follow up postal questionnaire was sent to all patients. This included, Visual Analogue Score (VAS) for Pain now and VAS for pain over one week, overall patient satisfaction, and Oswestry disability Index (ODI), The non-respondents were contacted by telephone 3 weeks later. Overall response was 100%.

RESULTS: Mean time from the onset of symptoms to coccygectomy was 23.8 months (range 5–72). Average length of follow up was 3.8 years (range 0.7–10.8).

6 patients (46%) had 0 pain for VAS now and VAS over one week. 2 patients (15%) had mild pain VAS (1,2) for pain now and over 1 week, and 4 patients(31%) had moderate pain VAS (5,5,5,6) for pain now and VAS (5,5,5,5) for pain over 1 week and 1 patient (8%) had severe pain VAS (8).

ODI was normal or mild disability (0–20%) in 8 patients (71%), 4 patients had moderate disability (ODI 21–40%) and 1 had sever disability (ODI 54%).

Overall Ten patients (76.9%) were satisfied with the result and would consider the same surgery again.

Conclusion: Surgical treatment of post traumatic coccydynia resistant to conservative measures can lead to satisfactory results, if appropriate patient selection criteria are applied.

Aim: To assess the functional outcome following spinal infection.

Method: 42 patients who had been treated in our unit for primary spinal infection between 1995–2005 were identified. 33 who were still alive at the time of study, were sent postal questionnaires. Average length of follow up was 5.4 years (rang 0.6–10.5). The non-respondents were contacted by phone two weeks later. Overall 29 (88%) were traced.

Results: Mobility score dropped in 10 (34%) patients whilst domestic circumstances’ score dropped only in 1 (3.4%). Oswestry disability score averaged 18% (range 0–53%). 16 (62%) had mild or no disability, 7(27%) had moderate and 3 (12%) had severe disability. Neck disability index in all those with cervical spine infection was between 10–20% indicating mild disability. Hospital anxiety and depression score for anxiety was normal for 25 (86%) and that for depression was normal for 27(93%) patients. Ten point Visual Analogue Score (VAS) for pain intensity when doing the questionnaire averaged 1.3 (range 0–9) with 19 (66%) having no pain, 9 (31%) mild to moderate (1–5 score) and 1 (3%) having severe pain (6–10 score). Mean VAS over one week was 1.8(range 0–9) with 14(48%) having no pain, 13(45%) mild to moderate and 2 (7%) having severe pain. VAS for distress averaged at 1.8 (range 0–9), 22 (76%) patients were coping very well (8–10 score) and poor coping (0–4 score) was seen in 1 (3%).

Conclusion: Most patients after spinal infection return to activities of daily living with little or no pain and psychological sequelae. A proportion of patients however end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection.

Objective: To report a consecutive series of patients who underwent staged reduction and fusion with the Magerl External Fixator and 360° fusion for high grade slips and spondyloptosis.

Design: Prospective observational study.

Patients & methods: There were 11 patients, average age 17 years (range 9–25 years).

All these patients had equal or greater than Meyerding grade III slips.

Clinical presentation included severe back pain with disability and a severe cosmetic deformity (including flexed knees, proptotic abdomen and loin creases).

The indications for surgery were pain relief and neurological symptoms/signs, and to improve the sagittal alignment.

Surgery consisted of first stage Gill procedure, L5 root decompression, and insertion of Schanz pins into L4 pedicles and ilium, and application of the fixateur-externe. Second stage consisted of gradual correction of kyphosis and translation (average 1 week duration). Third stage entailed anterior interbody fusion, removal of fixator and instrumented fusion L5 to sacrum.

Outcome measures: Functional out comes (pain scores [VAS], activities of daily living) cosmesis, complications (including neurologic status) and radiographic parameters.

Results: Average follow-up was 3 years and 3 months. Postoperatively none of these patients developed a neurological deficit. Imaging confirmed solid fusion in all patients. In terms of reduction, 1 patient failed to reduce (fusion in-situ) and 1 patient developed subsequent L4 on L5 spondylolisthesis. There was no case of permanent neurologic deficit.

Nine (82%) patients reported improved pain scores on the VAS, improved quality of life and cosmetic appearance.

There was significant reduction of the translation (in most cases to grade II) and correction of the lumbosacral kyphosis. All patients went on to a solid arthrodesis and there was no late loss of correction.

Conclusions: Staged reduction and Fusion not only improves a severe cosmetic deformity but also restores sagittal balance. We recommend this technique as there is negligible risk of neurological complications, and avoids fusion involving two motion segments.