Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

Introduction

IM (Intra Medullary) nail fixation is the standard treatment for diaphyseal femur fractures and also for certain types of proximal and distal femur fractures. Despite the advances in the tribology for the same, cases of failed IM nail fixation continue to be encountered routinely in clinical practice. Common causes are poor alignment or reduction, insufficient fixation and eventual implant fatigue and failure. This study was devised to study such patients presenting to our practice and develop a predictive model for eventual failure.

Introduction

Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic.

Background

The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications.

Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days.

We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed.

The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback).

Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy.

Surgery for spinal deformity was previously carried out only in teaching hospitals in the United Kingdom. With increasing numbers of patients especially adults, seeking treatment for spinal deformity, the number of centres offering treatment for spinal deformity is going to have to increase.

The deformity part of the Spinal Surgical Service in the District General Hospital in Taunton started in 2005. This paper is an audit of this deformity service. It looks at two key areas – that of patient satisfaction and patient reported outcomes of surgery. Patient satisfaction was assessed by a validated questionnaire that evaluated a patient's perception of consultations, consent, preoperative assessment, operative and post operative experience and follows up visits. Patient reported outcomes were evaluated using the SRS 30 questionnaire. 104 patients were contacted and 95 patients (91%) responded. The overall patient satisfaction rate was 96%, with 87% very pleased with the result of surgery, 80% felt that their body shape had improved considerably, 62% had an increased ability to carry out day to day activities to a much higher level and 78% had significantly decreased pain after surgery. The results of the different domains of the SRS questionnaire also supported this.

The authors believe that this audit proves that it is possible to provide a spinal deformity service in a District General Hospital in the United Kingdom safely and effectively with a high degree of patient satisfaction. Audits of this kind are required to compare results of treatment between different centres and establish standards.

Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively.

15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression.

We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia.

Introduction: With recent concerns about the prevalence of Clostridium difficile, some Orthopaedic departments have changed their antibiotic prophylaxis for hip arthroplasty patients. Are these decisions evidence-based and are the changes in the best interests of the patient? We have gathered information from hospitals across the UK to investigate whether prophylactic regimens are changing and what is driving this change.

Methods: Information was gathered using a questionnaire. This was sent via e-mail to hospitals in the Mersey Deanery, the East Anglian Deanery and other hospitals across the UK.

Results: Replies were received from 21 hospitals in total. The vast proportion is still using cefuroxime 1.5g on induction with 2 post-op doses of cefuroxime 750mg. Those that have changed are mainly using flucloxacillin/gentamicin although decisions regarding prophylaxis are being driven by microbiologists/management (cost implicated in 10%) rather than clinicians/clinical evidence.

Discussion: The AAOS has recommended that antibiotics used for prophylaxis should be carefully selected. They should be consistent with current recommendations in the literature, taking into account issues of resistance and patient allergies. In 2007, the DoH recommended prudent antibiotic prescribing to reduce the use of broad spectrum antibiotics as an important component in preventing and controlling Clostridium difficile. Nelson postulated in a Cochrane Database Review in 2007 that in treating Clostridium difficile-associated diarrhoea in adults, teicoplanin appeared to be the best choice because evidence suggests that it is better than vancomycin for bacteriologic cure and has borderline superior effectiveness in terms of symptomatic cure. The combination of teicoplanin (covering Gram positive organisms including MRSA and enterococci) an gentamicin (covering aerobic Gram negatives and staphylococci) would surely be in the best interests of the patient despite the cost.

Introduction: Prosthetic Disc surgery is a rapidly growing field in patients with symptomatic degenerative disc disease. Few reports of long-term follow up are yet published, but several authors have published case series including reports of significant complications and difficulties with revision surgery¹. Advocates of disc replacement surgery have claimed that Osteolysis, whilst being a potential problem associated with artificial disc replacement, has not yet been reported².

Methods: We present what we believe is the first histologically proven case of significant Osteolysis associated with artificial disc replacement in the world literature. We also present a literature review of the laboratory research into performance of artificial disc replacement, focusing on wear debris and particle generation.

Results: Our report involves a 42-year-old lady with degenerative disc disease who underwent L5/S1 anterior lumbar interbody fusion in July 1999, with a simultaneous L4/L5 Charite disc prosthesis. In May of 2002 she developed significant back pain, and further investigation, including biopsy revealed polymer disintegration and associated Osteolysis. Attempted revision surgery in May 2003, using a combined anterior approach by a vascular and spinal surgeon, led to damage to the adherent common iliac vessels and inferior vena cava, and the attempt to remove the prosthesis was abandoned. Histological samples taken at surgery confirmed the presence of polyethylene wear debris. Posterior instrumented fusion was performed in June 2003 and the patient made a successful recovery.

Discussion: It is important in modern spinal practice to be fully aware of both reported and potential risks of the use of new prostheses. We report an important complication associated with the use of artificial disc replacement. Revision of such prostheses is challenging, and we advise a combined surgical approach.

Introduction: Anterior lumbar interbody fusion (ALIF) with posterior stabilisation is an established treatment for degenerative disc disease.¹ Some previous reports have advocated a goal of 360 degree fusion, and condemned posterior stabilisation as it does not achieve fusion of the posterior facet joints.² Others have claimed that the concept of a ‘locked pseudarthrosis’ gives satisfactory clinical results.³ There is also a contention that private or self-funding patients achieve better results after spinal fusion compared to those treated under compensation or Dept. Veterans Affairs (DVA) schemes.

Methods: Twenty patients who had undergone an ALIF with posterior stabilisation were retrospectively reviewed. All had a follow-up greater than 12 months. 13 patients were private and 7 non-private. The groups were aged and sex matched. Radiological assessment of fusion was made with reconstruction CT scans. Oswestry Disability Index (ODI) scores were recorded preoperatively, 6 months and 12 months post operation.

Results: Patients with locked pseudarthrosis showed no significant difference in outcome compared to those with radiological fusion. Both groups showed signifi cant improvement in ODI scores after ALIF (mean preop. = 52 – range 16-74; mean postop. = 18 – range 0-52; p< 0.01). There was a significantly greater improvement (p< 0.02) in ODI scores in private patients (mean reduction = 41 points) compared to worker’s compensation or DVA patients (mean reduction = 22 points).

Discussion: The results indicate that ALIF with posterior stabilisation can achieve good clinical results even with a ‘locked pseudarthrosis’. While there is no significant difference between outcomes in different health funding groups shown in the study, carefully patient select for this treatment is the key to success.

Introduction: Diaphyseal femoral allograft is well suited to anterior column reconstruction of the thoracolumbar spine due to its inherent structural properties and bio-compatibility. The Bridwell system of interbody fusion assessment¹ is based on plain x-rays and therefore lacks sensitivity. A new classification system of bony union is proposed using high-speed spiral CT imaging.

Methods: Twenty-six patients who underwent anterior thoracolumbar reconstruction for burst fracture using femoral allograft were followed for a minimum of 2 years. Each subject underwent high speed spiral CT scanning through the reconstructed region of the thoracolumbar spine and a classification system of graft to endplate union and central cancellous autograft incorporation was established.

The classification system reflects gradually increasing biological stability of the construct. Grade I (complete fusion) implies cortical union of the allograft and central trabecular continuity. Grade II (partial fusion) implies cortical union of the structural allograft with partial trabecular incorporation. Grade III (unipolar pseudarthrosis) denotes superior or inferior cortical non-union of the central allograft with partial trabecular discontinuity centrally and Grade IV (bipolar pseudarthrosis) suggests both superior and inferior cortical non-union with a complete lack of central trabecular continuity. Intra- and inter-observer error studies were carried out involving spinal surgeons, radiologists and trainees to examine reliability of the classification

Results: In this series 84% of cases demonstrated Grade I or Grade II characteristics. 1 case (4%) was identified as Grade IV. The classification showed good reliability with a kappa score of over 0.7

Discussion: Plain radiographs have always proved unsatisfactory for the accurate assessment of incorporation of grafts in the thoracolumbar spine. The use of CT imaging in the assessment of graft union has allowed a more accurate assessment of union. The classifi cation system presented allows a reproducible and relevant categorisation of allograft incorporation.

Introduction: Vertebroplasty using polymethylmethacrylate (PMMA) is an established technique in the treatment of osteoporotic fractures of the vertebra. Complications of vertebroplasty associated with PMMA leakage can include damage to the spinal cord. Previous studies have sought to investigate thermal changes in the paravertebral region, but used smaller volumes of cement than are used clinically¹, or used in vitro experimental techniques.² We have designed an in vivo sheep model to investigate the thermal changes after injection of clinically relevant volumes of PMMA, and to measure change in cord function associated with PMMA extrusion.

Methods: Five sheep were anaesthetised and 1.0ml of PMMA was injected into the spinal canal at the L1 level, with measurement of the temperature by thermocouple. The L2 to L5 vertebral bodies were then exposed and 9 thermocouples placed at points in and around the vertebra (superior and inferior endplate, disc above and below, central body, posterior wall, and spinal canal) to measure paravertebral temperature for a 10- minute period after injecting 6.0mls of PMMA. All animals were then humanely euthanased, and the T12 to L2 vertebrae harvested to examine the effect of temperature on the vertebral body and spinal cord using light microscopy.

Results: The experiments showed significant increases in the paravertebral temperature, especially at the end-plates (mean temperature 51.7°C, mean increase in temperature +16°C). This is contrary to studies using small cement volumes or in vitro conditions. Intradiscal and posterior wall temperature did not significantly rise. Spinal canal temperature reached a mean 75.4°C in the presence of “extruded” cement. Microscopic examination showed thermal damage to the spinal cord.

Discussion: The experiments indicate that neurological complications associated with vertebroplasty are likely to be thermally mediated, and that the analgesic effects of vertebroplasty are likely to be, at least in part, due to thermal damage to endplate neurological structures.

Introduction: Prosthetic disc surgery is a rapidly growing field in patients with symptomatic degenerative disc disease. Few reports of long-term follow up are yet published, but several authors have published case series including a report of significant complications and difficulties with revision surgery¹. Advocates of disc replacement surgery have claimed that osteolysis, whilst being a potential problem associated with artificial disc replacement, has not yet been reported.

Methods: The literature relating to the laboratory research into performance of artificial disc replacement, focusing on wear debris and particle generation is reviewed. Reports of complications are reviewed. A case of significant osteolysis associated with artificial disc replacement is reported.

Results: Our report involves a 42-year-old lady with degenerative disc disease who underwent L5/S1 anterior lumbar interbody fusion in July 1999, with a simultaneous L4/L5 Charité disc prosthesis. In May of 2002 she developed significant back pain, and further investigation revealed polymer disintegration and associated osteolysis. Attempted revision surgery in May 2003, using a combined anterior approach by a vascular and spinal surgeon, led to damage to the adherent common iliac vessels and inferior vena cava, and the attempt to remove the prosthesis was abandoned. Histological samples taken at surgery confirmed the presence of polyethylene wear debris. Posterior instrumented fusion was performed in June 2003 and the patient made a successful recovery.

Discussion: It is important in modern spinal practice to be fully aware of both reported and potential risks of the use of new prostheses. Wear of an artificial disc causing osteolysis is anticipated. This is believed to be the first case in the world literature of this important complication associated with the use of artificial disc replacement. Revision of disc prostheses with osteoly-sis is challenging, and a combined surgical approach is advised.

Introduction: The foot is an unusual site for presentation of Ewings tumour. Haemangioma of the vertebra is a common finding in adults, but is rarely reported in children.¹ Although rarely symptomatic, the lesion may cause diagnostic confusion particularly in the presence of comorbidity. A previous case report details an adult patient with a ‘pseudohaemangioma’ that was subsequently found to be an Ewings tumour.²

Methods: A review of the literature and a case report is presented of a boy with a Ewing’s sarcoma of the foot presenting with an asymptomatic lytic lesion in the spine.

Results: The 12-year-old male initially presented with pain and swelling in the right foot. Subsequent investigation and biopsy confirmed a diagnosis of Ewing’s sarcoma in the second metatarsal. The child received 5 cycles of combined chemotherapy, and the primary tumour was excised from the metatarsal with fibular graft reconstruction.

Part of the clinical work up had included an isotope bone scan, which revealed a focal area of increased uptake in the L1 vertebra. On MRI, the vertebral lesion had a ‘halo’ of high intensity signal with infraction of the upper vertebral endplate. There were no clinical symptoms arising from the vertebral lesion. The differential diagnosis of the L1 lesion suggested was either a meta-static Ewing’s tumour or an aggressive haemangioma. Given the possibility of a multifocal or metastatic lesion, a vertebrectomy and reconstruction with femoral allograft was performed. A second stage posterior stabilisation from T12 to L2 was performed. Histological examination of the resected vertebra revealed a benign capillary haemangioma. On recent review one year after treatment, the patient remains in remission from his tumour and has successful graft incorporation with minimal symptoms from his spine.

Discussion: Haemangioma is a benign tumour commonly found in the vertebral body. Asymptomatic spinal haemangiomas do not require surgical excision. Clinico-pathological distinction between vertebral haemangioma and metastatic disease can be difficult, particularly in children where the haemangiomata may be in a ‘blastic’ phase. The combination of an extremely unusual age of presentation and the presence of a separate malignant primary bone tumour in this patient introduced a significant clinical dilemma in treatment.

Introduction: There is increasing evidence that surgical treatment in tumour surgery can influence survival times. Renal cell carcinoma can lead to single or few sites of metastasis that are amenable to extirpative surgery with reconstruction in the spine¹. Such treatment can also be beneficial to improve quality of surviving years.

Methods: Retrospective cohort study of 10 consecutive patients treated for spinal metastatic renal cell carcinoma. Case note review and patient or general practitioner contact was used to ascertain number of metastases, treatment given, survival time from diagnosis and survival time from surgery. All primary tumours were treated with nephrectomy.

Results: Of the 10 patients, 6 had extirpative treatment, while 4 had palliative surgery including decompression of the neural elements. Patients treated with extirpative surgery to spinal metastases from a renal cell carcinoma primary had a significantly longer survival time from surgery to those treated with palliative decompressions alone. There were no significant differences in age or time from diagnosis to surgical treatment between groups. There were no cases of operative mortality, but significant intraoperative bleeding was encountered in extirpative treatment of the affected vertebra, despite preoperative embolisation.

Discussion: The role of surgical treatment in metastasis to the spine is of current interest. Our results have shown significant survival times are possible with extirpative treatment of renal metastases. Whilst this may not apply directly to metastases from other primary tumours, careful selection of cases and co-operation between spinal surgeons and oncologists is important to ensure maximal quality and length of survival for these patients. These cases are surgically challenging, and care is required to minimise and anticipate blood loss.