Background

Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with percutaneously inserted medial locking plates.

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.

We describe the clinical results of a technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a 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 were included in this prospective study. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. Patients had either no or grade I spondylolisthesis. Definitive pseudoarthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity.

A midline incision was used for surgery. The pars interarticularis defect was exposed and filled with autologous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace. The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma and two superficial wound infections which responded to antibiotic treatment. Follow-up was at 6 weeks, 6 months and at 18 months, and 24 months. Clinical assessments for all patients was via the Oswestry disability index (ODI) and visual analogue scores (VAS). At the latest follow-up, 18 out of the 20 patients showed a significant (p<0.05) improvement in their ODI and VAS scores. The mean post-operative ODI score was 8%. All patients had radiographs and CT scans which showed fusion rates of 80% in those patients followed up for a minimum of 24 months. This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index in 18 out of 20 patients studied with a minimum follow-up of 2 years.

Anterior cervical discectomy and fusion for radiculopathy and myelopathy has the complication of the development of adjacent segment degeneration. Furthermore, reoperations may be required to treat complications of fusion, such as non-union, graft collapse, or expulsion. Cervical disc arthroplasty lays claim to preserving cervical motion and reducing the risks of adjacent segment disease in the treatment of cervical radiculopathy.

We performed a prospective study in order to evaluate the radiological and clinical outcomes of cervical disc arthroplasty for single or two level disc disease with associated radiculopathy. Our study included a total of 26 patients. Each patient had cervical radiculopathy from nerve root compression due to degenerative disc disease at one or two levels. Diagnosis was made preoperatively on clinical examination and by means of MRI scanning. Each patient also had preoperative flexion and extension cervical spine x-rays in order to assess pre-operative range of neck movement.

The outcomes of surgery were assessed prospectively. Range of motion at final follow-up was measured by flexion and extension view x-rays of the cervical spine. Clinical outcome was assessed by means of VAS scores for pain, SF12 for mental and physical health and the neck disability index (NDI). All complications were recorded. 14 of the patients had a follow-up for two years and the remaining 12 patients had a follow-up for one year.

A Discovery disc arthoplasty by Scient'X was the implant used in all patients. A standard anterior cervical approach was used to achieve decompression and for the implantation of the prosthesis.

On follow-up all patients had either maintenance or an improvement in the range of movement. There was no evidence of progression of degeneration in the segments adjacent to the arthroplasty prosthesis. Improvements in SF12, VAS, and NDI scores were seen from preoperative levels in 25 of the 26 patients. Complications included one patient with a horse voice post-operatively and one patient with minimal improvement of radicular symptoms. Post-operative MRI scanning demonstrated adequate decompression with this procedure and showed no evidence of progression of adjacent segment disease. There were no cases of implant subsidence or dislocations.

We have found cervical disc arthroplasty to produce good clinical outcomes when used for single or two level cervical radiculopathy whilst maintaining neck motion with an acceptable complication rate. A longer follow-up is needed to further assess the risk of development of adjacent segment disease but we did not discover the development of adjacent segment disease in our study with a follow-up of upto 2 years

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.

Objective: We prospectively compared the techniques of skip laminectomy and laminoplasty for the treatment of cervical spondolytic myelopathy in terms extent of decompression achieved, axial pain, postoperative range of cervical motion, patient and surgical outcomes.

Methods and results: We studied fifty consecutive patients operated on for cervical spondolytic myelopathy and spinal cord compression as demonstrated on MRI between the levels C3–4 to C6–7. Each patient had a minimum follow-up of two years (2.2 – 4.3 years). Twenty-five patients underwent skip laminectomy and twenty-five patients underwent laminoplasty. Decompression was assessed by pre- and post-operative MRI. Cervical range of motion was assessed by pre- and postoperative flexion and extension radiographs. Patient outcomes were assessed by evaluation of pre-and postoperative neurology and SF12 scores for mental health, physical health and axial pain.

Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy.

Conclusion: Skip laminectomy is an effective procedure for reducing the incidence of postoperative morbidities, such as persisting axial pain, and restriction of neck motion often seen after laminoplasty, and provides adequate decompression of the spinal cord as demonstrated on MRI for a minimum follow-up of two years.

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.

Summary. Between January 2003 and October 2004,12 patients with non tuberculous spondylodiscitis were treated by radical debridment, reconstruction and stabilization. In our group 9 patients underwent posterior procedure and 3 underwent combined anterior and posterior procedures. 3 of these had fungal and 9 pyogenic infections. All the patients had appropriate antimicrobial therapy All patients had excellent to good functional results and no evidence of infection at 2 year follow-up.

Introduction. Surgical treatment of nontuberculous spon-dylodiscitis of lumbar spine is challenging due to extensive bone involvement and comorbid conditions. This study is to assess the role of radical debridment followed by reconstruction and stabilization of affected segments in reducing morbidity and mortality in these patients.

Methods. 12 consecutive patients were operated between January 2003 and October 2004. Patients presented with severe back pain, root compression or paraparesis.7 cases had prior spinal surgery. Blood and radiological investigations were diagnostic. All these patients underwent radical debridement, reconstruction and stabilization of affected segments done with titanium pedicular screws, titanium mesh cages, cancellous iliac crest graft. Only posterior procedure in 9 cases, combined anterior posterior in 3 cases followed by adequate and appropriate antimicrobials therapy. Follow-up ranged from 25 to 35 months.

Results: 3 cases were fungal and 9 were pyogenic infection. Oswestry low back questionnaire, kirkaldy-willis criteria showed dramatic improvement of function. All the blood parameters were normalized in 3 months.1 case had dural tear which was repaired immediately,3 cases had wound exploration and lavage. No major complications were encountered. All cases showed Radiological fusion at last follow-up.

Discussion: Radical debridement of necrotic material, decompression of neurological structures, create a good vascularised environment. Restoring stability compromised by either infection or prior surgery helps in healing process and reduces morbidity of patients

Significance: Reconstruction using pedicular system and interbody devices can safely be used in presence of non tuberculous infection provided debridement has been radical.

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 and aims: Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

Method: We have operated on 147 patients with Spinal Tuberculosis between 1990 and 2001. Between 1990 and 1995 we treated 45 patients in the traditional manner with anterior decompression and strut grafting. During this period we encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis.

Between 1995 and 2001 we adopted the practice of anterior radical surgery combined with instrumentation (mesh cages and modern multisegment hook/screw system), and employed this approach in 102 patients. Of these: 28 patients underwent surgery at dorsal vertebral level, 35 at dorsolumbar level, and 39 at lumbar level.

Our experience has enabled us to develop a protocol in the management of these patients depending on:

The level of vertebral involvement (cervico-dorsal/ dorsolumbar/lumbar),

In dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by the posterior surgery. In dorsal lesions with deformity we performed Back-Front-Back procedure. In dorsolumbar lesions with single level disease we did anterior procedure only. In presence of multisegment involvement with or without deformity we did Back-Front-Back procedure. In lumbar lesions with anterior and middle column involvement without deformity we performed anterior surgery only. In lumbar lesions with all column involvement with deformity we performed anterior and posterior surgery.

Results: With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology), occurred in this group.

Conclusion: We conclude that Instrumentation in Spinal Tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.