To determine the cost-effectiveness of Lumbar Total Disc Replacement (LTDR) with circumferential spinal fusion surgery.

Cost utility analysis.

We prospectively reviewed a cohort of 32 consecutive patients who underwent LTDR between 2004 and 2008 with a mean follow-up for 3.75 years. Identical data was compared to a similar group of patients (n=37) who underwent fusion in our institution.

Oswestry Disability Index, visual analogue scale, quality of life (SF-36) and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. QALY gains were estimated from SF-36 data using standard algorithms.

There was no significant intergroup difference in the ODI, VAS and SF-36 pre and post-op. Both treatments produced statistically significant and equivalent improvements in mean health state utility at the 24-month follow-up (0.078 for LTDR, 0.087 for fusion). Costs were significantly lower with LTDR than with fusion due to a shorter mean procedure time (193.6 vs 377.4 minutes) and shorter length of stay (5.8 vs 7 days). The mean cost difference was £2,878 per patient. At 2 years, the cost per QALY gain of the lower-cost option (LTDR) was £48,892 although the cost effectiveness ratio would fall to below £30,000 if it is assumed that the patient benefits of LTDR last for at least 4 years.

Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with LTDR which is effective and a more cost-effective alternative.

Literature review about the current management strategies for U-shape sacral fractures

A thorough literature search was carried out to find out the current concepts in the management of U-shaped sacral fractures.

Meta-analysis of 30 cases of U-Shaped sacral fractures

Radiological assessment for bone healing, and clinical examination for neurological recovery.

7 papers were published in the English literature between 2001 and 2009 about the management of U-shaped sacral fractures. In total 30 cases were included. The most common mechanism of injury was fall or jump from height (63%), followed by road traffic accidents and industrial injuries. Pre-operative neurological deficit was noted in 73% of patients. The average follow up time ranged from 2-12 months.

18 (60%) of patients were treated with sacroiliac screws. In this group pre-operative neurological deficit was found in 12(66%) patients. All of these patients had satisfactory radiological healing at follow up but 5(27%) patients had residual neurological deficit. No immediate complication was reported in this group. Incomplete sacroiliac screw disengagement was reported in one patient without fixation failure. Other procedures performed were lumbopelvic fixation, triangular osteosynthesis and transsacral plating.

The most common cause of U-shaped sacral fractures is a fall or jump from height. There is a high association of neurological damage with U-shaped sacral fractures. From the current available evidence sacroiliac screw fixation is the most commonly performed procedure, it is however not possible to deduce which procedure is better in terms of neurological recovery.

To review the accuracy of our systematic process in preventing wrong level lumbar microdiscectomy.

X-ray is used to identify the correct level for the skin incision to be made, x-ray is again used if the surgeon is in doubt prior performing the flavotomy. Following a lumbar microdiscectomy a Watson Chane is inserted into the empty disc space and an intra-operative x-ray is taken to confirm the level the discectomy has occurred. Observers A and B independently reviewed intra-operative x-ray in patients undergoing lumbar microdiscectomies and correlated the accuracy of the x-ray in determining correct level surgery against the pre-operative MRI scan and the preposed level of surgery.

123 patients, 66 males and 57 females underwent 127 lumbar microdiscectomy procedures between 2007 and 2009. The levels where surgery occurred are;- L2/3 -1 patient, L3/4–8 patients, L4/5–53 patients and L5/S1-65 patients.

Kappa coefficient was used to determine inter-observer and Pearson Correlation coefficient was used to determine the X-ray and MRI relationship

Percentage of patients who required a pre-flavotomy x-ray level check are:- L2/3–100%, L3/4-63%, L4/5–45%, and L5/S1–40%. Pearson's correlation in confirming the level lumbar microdiscectomy was performed using final x-ray and the pre-operative MRI scan was 1. Kappa coefficient between observer A and B was 1.

This process of using intra-operative x-ray in determining the exact level where lumbar microdiscectomy was performed is 100% accurate. This is our standard process in preventing wrong level surgery for lumbar microdiscectomy.

To determine if there is a safe osseous corridor for trans-sacroiliac screw fixation of U-type sacral fractures using fluoroscopic landmarks.

We reviewed the sacral anatomy of patients who underwent Computed Tomography (CT) investigations between October and December 2009. Agfa-IPMAX Version 5.2 software was used to determine if there was a trans-sacroiliac osseous corridor in the S1 and S2 vertebrae from one ilium to the other.

76 patients were in the study, 38 male and 38 female. Exclusion criteria were patients under 18 years old; patients with degenerate lumbar spine and lumbo-sacral junction; CT imaging slices greater than 2.5mm.

We measured various parameters including the dimensions of the S1 and S2 mid-sagittal vertebral body; cross-sectional areas of the S1 and S2 corridor; location of the centre of the S1 and S2 corridor.

The mean cross-sectional area for S1 and S2 corridors in males and females are 21mm² and 15mm² respectively. The mean cross-sectional area for the S2 corridor in males and females were 15mm² and 11mm² respectively. The centre of the S1 and S2 corridor is located in the centre of both S1 and S2 vertebrae.

Two-thirds of males and females have a complete osseous corridor to pass a trans-sacroiliac S1 screw. The S2 corridor was present in all males but only in 87% of females. Before placement of trans-sacroiliac screws, the surgeon should review the CT sacral anatomy to determine if the trans-sacroiliac osseous corridor is present.

Ethics Approval: None – Audit Interest Statement: None