To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation.

Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008).

Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group.

Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms

NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows

The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel.

MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder.

Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory.

Previous research has suggested that when subjected to painful lumbar stimulation, chronic low back pain (CLBP) patients with illness behaviour (IB) are unable to effectively engage a sensory modulation system utilised by patients without IB¹. Furthermore, reduced insular cortex volume in CLBP patients with IB, may compound this problem².

Pain Management Programs (PMP) has demonstrated reductions in IB and disability associated with chronic pain conditions. This current study aims to assess whether the pattern of cerebral response to pain in IB patients could be normalised by participation in a PMP.

12 patients with CLBP and IB (>4/5 Waddell signs present) were recruited prior to attending a 16-day PMP. FMRI scanning occurred prior to (PrePMP) and upon completion of the PMP (PostPMP). 8 healthy volunteers (HC) were scanned once.

As in previous research, painful stimuli consisted of intense electrical stimulation delivered bilaterally to the lower back. The presentation of 3 colours indicated the likelihood of receiving 10second stimulation to the lower back (Always, Never and Maybe).

IB scores were significantly reduced PostPMP (p <0.05). FMRI group activation maps for the Always condition revealed PostPMP patients increased activation in posterior regions, areas similarly activated by HC. For the Maybe condition, compared to PrePMP group, HC demonstrated greater activation in precuneus and middle and inferior frontal regions. Compared to their pre-treatment selves, PostPMP patients demonstrated increased activation in posterior and frontal regions.

The results demonstrate that completion of a 16-day PMP leads to alteration in the brain's response to painful low back stimulation in CLBP patients with IB. Increased activation is seen in regions associated with the top-down modulation of pain. The response is similar to that seen in HC, and greater than before PMP confirming that the PMP process facilitates the utilisation of more normal coping pathways in response to CLBP.

To assess the effectiveness of dynamic stabilisation as a treatment for discogenic pain compared to standard treatment of interbody fusion.

All patients were referred for a 2 year back-pain management programme. Patients with continued pain following conservative treatment underwent discography & MRI. Patients with painful degenerate discs on the above investigations were selected.

Patients underwent interbody fusion (PLIF/TLIF) or dynamic stabilisation.

Mean follow-up was 24 months with a minimum follow-up of 12 months.

All patients had pre-operative ODI and VAS scores. Patients were then sent further questionnaires at 6 month intervals.

The mean improvement in ODI following dynamic stabilisation was 20% (-20% → 56%), the mean improvement in the pain score was 2.4 (0→8).

The mean improvement in ODI following interbody fusion was 11% (-14%→48%), the mean improvement in the pain score was 2.6 (-4→9).

10 patients in the dynamic stabilisation group had a greater than 20% improvement in ODI, 7 patients in the interbody fusion group had similar results.

The above results demonstrate that dynamic stabilisation is at least as effective at treating discogenic pain as interbody fusion. The results however do question the validity of either interbody fusion (PLIF/TLIF) or dynamic stabilisation in the management of discogenic pain.

Determine the detection rate of modern spinal implants using the current technology.

There is a paucity of data regarding detection rates of modern spinal implants using modern walk-through pulsed archway metal detectors (AMDs). No published reports compare detection capability with hand-held metal detectors (HHMDs).

ex-vivo & in-vivo comparison of detection rates using AMD & HHMD (set to maximum DoT sensitivities), in patients of varying Body Mass Index (BMI), implants, implant mass/density and alloys.

40 patients with: lumbar disc replacement (CoCr) (n=8), cervical disc replacement (CoCr) (1), posterior deformity instrumentation (17), anterior deformity instrumentation (2), anterior reconstruction (2), PLIF (6), interspinous distraction device (1), anterior cervical plate (2) ALIF (1), All implants were titanium unless indicated. Mean metal mass was 98g (range 6g-222g).

The AMD did not detect any instrumentation individually or in combination up to a titanium mass totalling 215g. The HHMD detected all instrumentation at a distance of 5cm; with the minimum mass being 2g

No implants were detected in patients by the AMD. The HHMD did not detect any anterior lumbar or thoracic surgical implants. It detected anterior cervical implants. The HHMD detected all posterior surgical implants. There was no significant relationship between detection, BMI, total metal mass, and metal density/segment.

AMD detectors do not detect modern spinal implants. HHMD detect all modern posterior spinal implants; this has implications for patient documentation.

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.

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.

Compare the prevalence of psychological distress in claustrophobic patients compared with a non-affected group, together with determination of presenting disability and overall intervention rates.

Retrospective case notes review.

33 patients (13 males) all requiring MRI scan under sedation for claustrophobia (Group 1) were compared with an age and sex matched cohort that had MRI without sedation (Group 2). Both groups were drawn from the same chronic back clinic. Average age in both groups was 54 years (range 27-79 years). Both groups had standard conservative therapy, together with psychometric evaluation.

Primary: Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ). Secondary: Oswestry Disability Index (ODI), intervention rates (surgery, injections and physiotherapy sessions)

Comparison of means -

22 patients (66.7%) in Group 1 were discharged after their MRI with no intervention compared to 7 patients (21.2%) in Group 2.

Claustrophobic patients with back pain showed higher levels of depression than non-claustrophobic patients, with a greater prevalence of psychological distress. Disability however was the same. The majority of claustrophobic patients had no intervention, with a lower rate than their non-claustrophobic peers. Claustrophobia is a proxy for psychological distress and should be considered in the overall evaluation of chronic back patients.

Comparison of efficacy of multi-modality spinal cord monitoring [SCM] (SSEP & MEP) in surgery of paediatric deformity using two classification systems I (traditional) vs. II (modified).

SSEP SCM has low sensitivity in a normal spinal cord; this is only marginally improved with additional MEP monitoring. Traditional definitions of a ‘false’ positive' test ignores anaesthetic & surgical interventions following notification of altered SCM signals.

Retrospective, paediatric cohort.

232 patients; mean age 14 years (26% males). 68% idiopathic scoliosis; 62% posterior surgery.

Primary: Post-operative neurologic deficit. Secondary: significant (>50%↓ amplitude) SSEP or any MEP loss.

PPV- Positive predictive value, NPV- Negative predictive value; LR+ve- Positive likelihood ratio, LR-ve Negative likelihood ratio; N/C – Not calculable

Efficacy of SCM is determined by definitions of ‘false positive’. System II classification was more efficacious and reflects current surgical practice.

To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group.

Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009).

Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions.

Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain

C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1).

C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm).

Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved.

No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs.

3 patients had C2 numbness. No other neurological deficit.

In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes.

We carried out a prospective study looking at the functional outcome and post-procedure segmental instability after lumbar decompression using a flip osteotomy technique that involved unilateral subperiosteal muscle dissection with hinging of the spinous processes thereby preserving the integrity of the posterior elements for unilateral or bilateral lumbar spine decompression.

Between February 2007 and February 2008, 51 patients (29 male and 22 female) diagnosed with degenerative and congenital lumbar stenosis with an average age of 60, underwent central and lateral canal decompression using the flip osteotomy technique. An average of two segments (range 1-3 segments) was decompressed. Patients with a history of previous spinal surgery, spinal fusion, existing degenerative spondylolisthesis or cauda equina syndrome were excluded.

All patients were followed up for a mean of 1.5 years. Five outcome measures were used – visual analogue scale for pain, Likert scale for functional status, symptom specific well-being score, general well-being score, number of days incapacitated in last 4 weeks. The outcomes measures were recorded pre-operatively, 6 weeks and one year post-operatively. Successful surgical outcome was defined as an improvement in at least four out of five outcome measures.

90% (46 patients) of patients had a successful surgical outcome. There was a statistically significant improvement in all outcome criteria (p<0.005) at the 6-week post-operative mark as compared to pre-operatively, with marginal improvement at one year post-surgery. There was no evidence of progressive lumbar segmental instability at one year post-operatively using our flip osteotomy technique

Decompression of the lumbar spine for lumbar stenosis using the flip osteotomy technique is a safe approach for one or multi-level stenosis with good outcomes and no evidence of significant iatrogenic segmental spinal instability.

We declare no conflict of interest and ethical approval was obtained

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.

To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA).

Cost-effectiveness analysis

Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months.

Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained.

Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated.

Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.

Ethics approval: Ethics committee COREC

This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based.

Spinal disc infection is associated with a significant morbidity and mortality in the acute setting. On long term review it leads to significant moribidity due to the deformity and secondary osteoarthritic changes in the surrounding vertebral segments.

Prospective collection of data of 21 patients suffering from discitis was collected over the span of last 10 years. The age group ranged between 21 -67 yrs. The male: female ratio was 1.2:1. The minimum delay in presentation since the onset of symptoms was 8 weeks. The detection of the micro-organism was either by needle/open biopsy or indirectly via blood cultures. Serial records were maintained of inflammatory markers. All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies

Operative decompression was performed in 7 patients. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 54% of spondylodiscitis cases. The erythrocyte sedimentation rate and CRP were elevated in all cases of epidural abscess. The most common organism was Staph Aureus. Antibiotics were administered for duration of at least 6 weeks. On long term, all patients developed deformity at the level of the infection, with half of them being symptomatic.

Spinal infections are extremely morbid conditions demanding prompt diagnosis and urgent treatment to prevent complications.

Ethics approval: Audit Committee Interest statement: No conflict of interest

Lumbar decompression-fusion surgery involves extensive surgery in prone position and is associated with significant post-op ileus. We compared the post-operative oral intake regimes of our two spinal firms over a 6 months period.

The post operative oral intake was commenced as soon as the bowel sounds started in one firm. In the other firm, the oral intake was started only after the patient passed wind. There were 28 patients in the first group (bowel sounds) and 27 patients in the second group (passage of wind). The two groups were comparable for age and sex distribution. The average age was 69 yrs, and the male: female ratio was 1.2:1.

The bowel sounds were found to start on an average of 8.5 hours (6-16 hours) post-operatively. The average time between the operation and the patient passing wind was 26 hours (18-73 hours). The patients who were on Patient Controlled Analgesia (PCA) were found to have a delayed passage of wind. There was no significant correlation between the number of fusion levels or the operative time and commencement of bowel sounds/ passage of wind

The patient satisfaction rate was much better when the oral intake was commenced as soon as the bowel sounds start. The incidence of nausea/vomiting was significantly less in the group in which the oral intake was commenced following patient passing wind. The bloating of the abdomen was found in the first group.

Audit Committee Interest statement: No conflict of interest

Consecutive case series

To evaluate the efficacy of a strict stepwise radioanatomical procedure protocol in avoiding neurological complications through tool malplacement in fluoroscopy guided percutaneous procedures of the thoracic spine.

Fluoroscopy guided percutaneous access to thoracic vertebral bodies is technically demanding. There is a trend towards computed tomography (CT) guidance on grounds of perceived lesser risk of spinal canal instrument malplacement. CT is however not always readily accessible and a safe technique for fluoroscopy guided procedures therefore desirable.

350 consecutive fluoroscopy guided percutaneous procedures (biopsy, vertebroplasty or kyphoplasty) covering all thoracic vertebral levels T1-T12 were performed according to a strict stepwise radioanatomical protocol. The crucial step of the protocol was not to advance the tool beyond the anterior-posterior (ap) projection of the medial pedicle wall until the tip of the instrument had been verified to have reached the posterior vertebral cortex in the lateral projection. The neurological status of patients was assessed through clinical examination prior to, immediately after the procedure and before discharge.

Percutaneous instrument placement in the targeted thoracic vertebral body was achieved in all cases and the stepwise radioanatomical protocol was followed in all cases. There was no case of neurological deterioration in the case series.

Conclusion: Attention to radiographic landmarks, specifically not crossing the ap projection of the medial pedicle cortex prior to reaching the posterior vertebral wall in the lateral projection, allows neurologically safe performance of fluoroscopy guided percutaneous procedures of the thoracic spine. This simple protocol is particularly useful when access to CT is limited.

Surgery of the spine is associated with blood loss and frequently transfusion, with consequent risk of infection and reactions. It also costly, and puts a strain on national blood banks.

A new blood salvage device works by ‘washing’ and centrifuging the blood lost during surgery; which can then be re-transfused into the patient.

In a retrospective study 46 consecutive spinal surgeries with Cell Saver were compared with 39 matched surgeries without. Blood loss and units transfused was obtained from the transfusion database and the anaesthetic record.

Average blood loss in the Cell saver group was 1382ml compared to 1405ml in the pre-Cell Saver group.

Average allogenic transfusion was 1.30 units with cell saver compared to 2.78 units without. An average 2.3 units of lost blood were re-infused in the Cell Saver group.

26 (57%) of the Cell Saver group require no allogenic blood at all, whereas only 10 (26%) of patients in the pre-Cell Saver group had no transfusions.

One unit of blood costs £130.52, and the Cell saver device costs £100 per patient. The average cost per patient in the Cell saver group was £270 (any transfusion plus cost of Cell Saver), compared to an average of £368.50 in the pre-Cell Saver group: a saving of £92.50.

The Cell Saver decreased blood transfusions by 46% per patient and by 40% overall, a saving of £92.50 per patient. The number of patients receiving no allogenic blood increased by 31%.

The purpose of this cohort study is to determine the incidence of all congenital vertebral anomalies detected antenatally through ultrasound. We also reported on the early mortality rate for this patient cohort, as well as the frequency and type of associated congenital anomalies.

The East Midlands and South Yorkshire Anomalies Register consists of data on all voluntary reports of congenital anomalies, from an annual baseline birth rate of 67000 births. We analysed all registered congenital anomalies reported over a 10 year period.

Between January 1997 and January 2007, 108 vertebral anomalies were reported, excluding spinal dysraphism (incidence 0.01%). 61 of these were detected antenatally (56%), 17 were detected postnatally (16%) and in 30 patients, the precise time of diagnosis was unclear (28%).

At the time of analysis January 2007, 45 of 108 patients had died, either in utero or soon after delivery (42%). 12 fetuses remained in utero and 51 infants were alive. The mortality rate for antenatally diagnosed patients was 41% and the majority were electively terminated (72%). 2 fetuses electively terminated had vertebral anomalies in isolation.

There is a relatively high incidence of elective termination of pregnancy as a result of antenatal anomaly ultrasound screening. We have evidence to suggest that foetuses with potentially minor congenital anomalies are being electively terminated at approximately 18 weeks gestation. A structured and timely spinal counselling should be offered once antenatal vertebral anomalies have been identified.

Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered.

To assess health care professionals knowledge with regards to urinary symptoms of CES and when treatment should be offered.

A 4-part questionnaire established profession and number of cases seen per week. The participant was asked to rank 15 urinary symptoms, 7 of these symptoms were not related to CES. The participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES.

Primary and Secondary Care

60 questionnaires were complete. Participants had to successfully complete the first three parts of the questionnaire (n = 44). Any who failed to complete section four were excluded from analysis from that part only (n = 41).

A total of 44 questionnaires were analysed. Both doctors and physiotherapists ranked the CES symptoms on average significantly higher than then the non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05).

87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours. 46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours.

These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment.

There is evidence that various anatomical structures have altered morphology with ageing, and anecdotal evidence of changing lumbar spinous process (LSP) morphology with age. This study aims to clarify the influence of age on LSP morphology, and on lumbar spine alignment.

200 CT scans of the abdomen were reformatted with bone windows allowing precise measurement of LSP dimensions and lumbar lordosis. Observers were blinded to patient demographics. Inter-observer reliability was confirmed.

The smallest LSP is at L5. The male LSP is on average 2-3mm higher and 1mm wider than the female LSP. LSP height increases significantly with age at every level in the lumbar spine (P<10^-5 at L2). The LSPs increase in height by 2-5mm between 20-85 years of age (P<10^-6), which was as much as 31% at L5 (P<10^-8). Width increases proportionally more, by 3-4mm or greater than 50% at each lumbar level (P<10^-11). Lumbar lordosis decreases in relation to increasing LSP height (P<10^-4) but is independent of increasing LSP width (P=0.2).

The height and width of the spinous processes increases with age. Increases in spinous process height are related to a loss of lumbar lordosis and may contribute to sagittal plane imbalance.

There are many various possibilities of treatment from observation and conservative treatment, over simple bony fusion to exacting hemivertebrectomies and deformity correction.

Retrospective analysis of various conservative and surgical techniques.

Subjects. The total number of 702 patients treated in our department since 1976 had been evaluated. An average follow up is 17 years.

Correction grade, security and efficiency of treatment methods, clinical results and complication rate were the main observed outcome measures.

Group A (conservative treatment) - 356 pts.

Group B (hemiepiphyseodesis) – 112 pts. Final result of correction was 9,8 degrees (22%).

Group C (posterior instrumentated fusion) – 147 pts. Final result of correction was 25,6° (38%).

Group D1 (anterior strut graft with posterior instrumentated fusion) – 27 pts. Final result of correction was 26° (40%).

Group D2 (anterior osteotomy with posterior instrumentated fusion) – 33 pts. Final result of correction was 28° (43%).

Group D3 (combined hemivertebrectomy with posterior instrumentated fusion) – 22 pts. Final result of correction was 31,3° (61%).

Group D4 (posterior only hemivertebrectomy with instrumentated fusion) – 5 pts. Final result of correction was 30,7° (61%).

Early detection, good timing and choosing of adequate surgical type are the main factors of quality treatment results. The best surgical method for formation failure types seems combined or posterior only instrumentated hemivertebrectomy and early hemiepiphyseodesis for segmentation failure types.

To analyse procedural details - specifically vertebral levels treated and injected polymethylmethacrylate (PMMA) volumes - of the publications by Buchbinder et al. ¹ and Kallmes et al. ² in the context of best available basic science.

Review

Two randomised controlled trials published by the New England Journal of Medicine (NEJM) in 2009 comparing vertebroplasty to sham procedures conclude vertebroplasty to be no more effective than injection of local anaesthetic. This finding contradicts previous publications showing clinical efficacy.

Neither investigation provides a breakdown of vertebral levels treated (original publication and supplementary material). Only one investigation provides information on fill volumes with average of 2.8 ml +/− 1.2 ml SD.

The available basic science indicates a minimum fill volume of 13-16% of the vertebral body volume to be necessary for a relevant biomechanical effect on restoration of vertebral strength, according to which only vertebrae of the upper to mid thoracic spine could reasonably have received a biomechanically effective fill with the declared average volume of 2.8 ml +/− 1.2 ml SD.

The available data of the NEJM publications strongly indicates that the treatment arm includes insufficiently treated patients. The technical information provided by the NEJM publications is insufficient to conclusively prove or disprove the clinical efficacy of vertebroplasty.

Lumbar myelography was a commonly performed procedure but was superseded by MRI and CT which were low risk and provided cross-sectional information. The majority of MRI and CT evaluations are static and supine whereas myelography may be loaded and dynamic. This study evaluates the role of myelography in patients with degenerative scoliosis in a modern surgical practice.

Patients with degenerative scoliosis and full imaging (plain radiographs, supine MRI, myelography, including CT myelography) were identified from our database between 2006-2009. Differences between findings of MRI and myelography/CT myelography were noted and whether this subsequently affected treatment.

21 patients fulfilled inclusion criteria. Mean age 68 (45-82), 17 females. 18/21(85.7%) myelograms revealed findings not seen on MRI. 15 patients had a single abnormality, 1 had two and in 2 patients there were 3 new abnormalities. These were facet/ligamentous bulging in 13, a single spondylolisthesis, retrolisthesis and lateral subluxation. On CT a foraminal osteophyte and a pars defect were seen. In 4 cases supine investigation revealed more than MRI. In 7 patients management changed as a result of myelography/CT. There have been no complications of myelography in our unit of the total 270 performed.

Myelography is a safe and useful tool in the management of patients with degenerative scoliosis. MRI scan alone understates the true nature of central and lateral recess stenosis. Not only does myelography show more stenosis in the loaded spine, but static myelography and CT myelography are also an invaluable tool in these patients.

8 patients with cervical myelopathy treated by French-door laminoplasty and internal fixation. A novel technique of fixation is employed to provide immediate stability, pain relief and rapid mobilisation.

To report the clinical and radiological outcomes of this new fixation device for French–door laminoplasty with minimum follow-up of 30 months.

Hardware assisted laminoplasty has the potential advantage of instant stability and prevention of recurring stenosis. The use of titanium mini-plates has been described in open-door laminoplasty and now we describe this technique in French–door laminoplasty.

8 patients with cervical myelopathy secondary to congenital stenosis (2) and multi-level spondylotic myelopathy (6) underwent 2-4 level French–door laminoplasty and mini-plate fixation. The average follow-up was 46.5 months. Autogenous iliac crest bone graft was interposed between the sagittally split spinous processes and 16-18 holed titanium mini-plates were contoured into a trapezoidal shape and secured to the posterior elements with screws. Patients then mobilised without external support.

The mean follow-up was 46.5 months. The mean improvement in NDI at final follow-up was 35% and mean improvement in VAS was 4 points. JOA score improved from a mean of 10 to a mean of 14.8 post-operatively. All patients had achieved a significant neurological improvement and pain relief. There were no post-operative hardware related complications, pseudarthrosis or neurological deterioration.

French-door laminoplasty is an excellent alternative to laminectomy for treatment of young patients with cervical myelopathy. The use of titanium mini-plates not only provides instant stability and pain relief but also seems to minimize the risk of C5 nerve root palsy. Internal fixation appears to provide instant stability, early mobilisation and therefore reduces hospital stay and associated costs.

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.

We are presenting a prospective analysis and assessment for the results of the Coflex@ inter-spinous dynamic stabilization device with a 2 year follow up. The purpose of this study is to assess the efficacy and safety of the Coflex@ Posterior Dynamic Stabilization Implant.

A prospective analysis was performed on 121 patients (176 devices) treated with the Coflex@ Interspinous Implant. Indication for the treatment was spinal canal foraminal stenosis with nerve root irritation.

Pre- and postoperative disability and pain scores were measured using Oswestry disability score, functional assessment a radiological evaluation at pre-operative - three - six twelve and twenty-four month interval.

Data analysis revealed a high rate of patient satisfaction 92% of patients are satisfied and will have the surgery again 81% of patients had major improvement of their leg symptoms. 72% of patients reported improvement of their back pain symptoms this was more noted in the decompression group.

Two revision surgeries were carried out. One due to implant back-out and the second due to infection.

The Coflex@inter-spinous implant is a simple surgical treatment strategy with a low risk. Early results show a good improvement of both clinical and radiological parameters combined with patient satisfaction with better outcome achieved if combined with spinal decompression.

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.

Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system.

Recurrence of spinal metastasis and radiological failure of reconstruction

All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications.

Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units.

There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization.

Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible.

A comparative audit of the Regional Spinal Injury Units in the UK and North American Units.

Regional Spinal Injury Units in United Kingdom and North America

Clear Management Plan

Mobilisation Schedule

We had replies from all Regional Spinal Injury Units in the UK and from seven in North America.

The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases.

The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management.

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

Reviewing our experience of scoliosis in children with a Cavopulmonary Shunt or Fontan circulation and the cardiovascular challenges that this presents.

A notes and x ray review was performed. Special attention was paid to the changes in cardiovascular status whilst prone. The review was from first presentation to latest follow up.

There were 6 patients who underwent 7 major procedures between 2001 and 2009. All had cardiac procedures in early life. Both definitive fusion and growing instrumentation was used. All procedures were successful. Growing instrumentation allowed earlier primary surgery before completion of the Fontan circulation. All have been subsequently lengthened in a lateral position. The mean follow up is 56 months. There was one death 40 months following last surgery, cause unrelated to spinal surgery.

In the older patients with a completed Fontan significant blood loss was seen, due to the raised venous pressure required to run the Fontan, and occult hypotension seen as a climbing difference between Pulmonary Artery Wedge Pressure and Central Venous Pressure were common when prone.

We recommend early intervention, using instrumentation without fusion to correct the deformity over time and allow intervention prior to completing the Fontan circulation. As haemodynamic instability increases with increasing time in the prone position, surgery should be expedited rapidly.

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique.

We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared.

Tumors were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group.

The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery.

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy.

Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD).

A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant.

Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes.

A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of thoracic and lumbar spine. To our knowledge this is the only study so far that has followed a cohort of patients prospectively until death.

Prospective study of patients with lytic tumours of spine treated with kyphoplasty.

A total of 13 patients with osteolytic tumours of spine were treated with kyhpoplasty. There were 8 female and 5 male patients. The age range was 52-81 years with average age of 65 years. A total of 25 vertebrae, from T2 to L3, were treated. The types of tumours included; non-Hodgkin lymphoma (2), myeloma (2), gastric-carcinoma (1), cervix-carcinoma (1), breast-carcinoma (3), prostate-carcinoma (2), small cell lung-carcinoma (1), bladder-carcinoma (1).

Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time.

The preoperative average VAS was 7.5 (range: 2.6 – 10). This dropped to 3.0 five days postoperatively and remained below 5 for the duration of follow-up. Average walking distance, standing and sitting time and ECOG performance score showed improvement. The survival time ranged from 2 to 293 weeks. The average survival time was 82 weeks. All patients were able to return home following the procedure. No patient required reoperation or readmission for spinal metastasis.

Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine.

To determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool

Radiological analysis.

A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later.

Reproducibility of the measurements was assessed using Bland and Altman plots. Accuracy was assessed using the Vernier calliper measurements as the gold standard and comparing the plots.

Perfect reproducibility was achieved when measuring the geometric objects with the Vernier callipers. The error of the measurement associated when measuring the pedicles was 0.5mm. The error of the measurement for the geometric objects for observers 1 and 2 was 0.5 and 0.6mm respectively, and for the pedicles it was 1.0 and 0.6mm respectively.

The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.

Ethics approval None Interest Statement None

Scoliosis school screening is either mandatory or recommended in 32 states in the USA. The remaining states having either got voluntary screening or no recommendations. The four primary care providers for adolescents with idiopathic scoliosis in the USA do not support any recommendation against scoliosis screening, given the available literature. In Australia a national self detection program is implemented but in the UK school screening has been abolished since the 1980's. Opponents to scoliosis screening have focused on concerns about a low predictive value of screening, the cost effectiveness of referral, the possibility of unnecessary brace treatment and the effect of exposure to radiation when radiographs are obtained.

The purpose of this review was to evaluate the evidence for and against scoliosis screening.

The following databases were searched: Cochrane Library, ARIF, TRIP, MEDLINE, EMBASE and CINAHL. Reference lists of articles were searched for relevant systematic reviews and research articles.

One systematic review (2008)¹ suggests that there is evidence (level 1B) that intensive scoliosis specific exercise methods can reduce the progression of mild scoliosis (<30 degrees Cobb). Further a Cochrane review (2010) suggests that there is low quality evidence for the effectiveness of bracing.

Based on the evidence of this review, a 4 tier model for school screening is proposed that addresses the “opponents” concerns. The model includes the distribution of information leaflets, screening by a school nurse, topographical assessment, referral to the primary care doctor and finally if the patient is still screening positive, referral to a scoliosis surgeon.

Exercises reduce the progression rate of adolescent idiopathic scoliosis:

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC.

Retrospective analysis

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15.

Neurological outcome and survival

A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery.

The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%.

There was no difference in neurological outcome between the 3 groups.

There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score.

To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC.

Retrospective review

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3).

Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups.

A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86).

The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03.

When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05).

When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009).

There was no difference in survival or complications between the groups.

Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates.

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

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks.

Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%.

In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice.

The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome.

Anonymous retrospective review

We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’

An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome.

A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%).

Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693).

The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409.

Ethics approval: None;

Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company

The purpose of this study was to ascertain whether early diagnosis through antenatal ultrasound screening and intervention lead to a reduction in morbidity associated with congenital scoliosis.

Prospective cohort study

All fetuses with vertebral body anomalies detected over a thirteen years period were included. Maternal risk factors, accuracy of antenatal diagnosis, associated fetal anomalies and ultimate outcome are described.

Twenty-four fetuses with congenital hemivertebrae were identified from 39,000 antenatal scans (incidence 0.061%). The mothers' median age at conception was 26 years (range 18-40 years). The median fetal gestational age at diagnosis was 20 weeks (range 18-38 weeks). The median gestational age at delivery was 38 weeks (range 27-40).

Antenatal ultrasound identified eighteen fetuses with a single hemivertebra, six fetuses with multiple hemivertebrae. Eleven patients (50%) have undergone early surgical intervention with median post-natal follow up was 4 years (range 0-9 years). The median age at surgery was 12 months (range 1.2 - 47 months). The median pre-operative Cobb angle was 33 degrees and the median Cobb angle at final follow up was 25 degrees.

In this series 50% of patients required surgical intervention. We felt that pre-natal diagnosis of congenital vertebra abnormally has resulted in early surgical intervention using less complex surgical technique to halt progressive deformity. However, further studies are required to compare the results with the abnormally not detected antenatally.

To examine the relationship between obesity (BMI> 30) and the incidence of peri-operative complications, outcome of surgery and return to work in patients undergoing elective less invasive posterior lumbar inter-body fusion of the lumbar spine for low back pain and leg pain (“LI-PLIF”).

15 patients with BMI> 30 who underwent (“LI-PLIF”) were identified by reviewing the clinical notes and the pre-operative admission sheet from April 2005- to March 2007. All had suffered chronic low back pain for a minimum of 2 years that had proven unresponsive to conservative treatment. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). Minimum follow-up was for 12 months.

Blood loss was dependent on BMI, number of levels, and surgical time. Post operative complication was more in the morbidly obese group than the in the obese. 10 patients (66.6%) returned to their normal pre-operative employment within the 12 months of the index procedure. There was a significant improvement in the ODI and in the VAS for back pain. Length of hospital stay was a mean of 3.3 days

Although surgery is technically more demanding our experience with less invasive posterior inter-body fusion has shown less incidence of post operative complication, less intra-operative blood loss and short in-patient hospital stay.

We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain.

Ethics approval: None: Audit Interest Statement None

It was noted that in our spinal theatre a constant cause of delay was lack of an available radiographer. This work describes our solution to this problem by training theatre staff to operate the imaging equipment for the simple single plane images required in spinal surgery.

Under the guidance of the trust's Radiation Protection Advisor to a training program for theatre staff was devised that encompassed the practical aspects of using the imaging equipment and the theoretical elements of radiation safety. All changes in practice complied with the radiation safety regulations IRR 99 and IRMER 2000.

The trained staff now work as independent operators in the spinal theatre. They work to a ridge protocol and have to report directly to a Radiation Protection Supervisor (senior radiographer) at the end of each list so that the images taken and radiation dosage can be verified.

Since the change of practice, the spinal theatre has been more efficient, performing up to one major case extra per list. The radiology department has benefited by having a radiographer freed to perform more complex procedures elsewhere. The operators have also commented on how they have found the whole process rewarding both professionally and personally.

The training of theatre staff to operate the imaging equipment in our spinal theatre has been a successful endeavour and at present the trust is currently planning to expand the program to include other surgical fields such as urology and laparoscopic surgery.

Centre Hospitalo-Universitaire de Lille, Service de Neurochirurgie et Chirurgie du Rachis, Lille, France.

Assessment of current thoughts regarding spinal fellowships amongst spinal fellows in the United Kingdom and abroad

Qualitative analysis provides rich and contextual detail that cannot be borne out by quantitative research. We undertook detailed interviews amongst fellows who have varying fellowship experience both in the United Kingdom and abroad.

Ten fellows, all of whom were approaching their Certificate of Completion of Training (or equivalent) in Trauma and Orthopaedic surgery, or just awarded the certificate. All undertaking/undertaken at least one 12-month fellowship.

Qualitative experiences

A large unit provides a breadth of pathology that may is usually not encountered in smaller units. Fellows who worked in such units felt confident that they would recognise a variety of pathologies, but did not necessarily feel confident in their surgical management. Operative exposure to deformity surgery, whilst not necessarily a future part of practice, was felt useful for the added technical skills it provides. Fellows attending a smaller unit, where they may have been the sole ‘spinal fellow’, reported greater satisfaction in operative experience.

Interestingly, there was felt to be a ‘saturation point’, where a fellow perceived no further educational benefit from remaining in one particular unit.

A fellowship in spinal surgery is useful in preparing for independent practice as a spinal surgeon. Large units provide skills that are applicable to several aspects of spinal surgery. There appears to be a difference in breadth and complexity of pathology versus operative experience.

Centre Hospitalo-Universitaire de Bordeaux, Service de Pathologie du la Colonne Vertébrale, Bordeaux, France.

Assessment of cervical lordosis using a standardised digital acquisition procedure in the normal population

Three independent reviewers measured static lordosis. The EOS¯ system, which utilises low dose radiation and provides reliable standardized digital 2D acquisition with 3D reconstruction was employed. Measurements were carried out twice by every examiner on two different occasions.

Cohort of the general public of 180 subjects divided into 4 groups (both sexes individually, age less than 40 and greater than 50 individually). None had any previous history of spinal disorders or sagittal imbalance. General cervical lordosis (C2 to C7) as well as upper and lower cervical lordosis were assessed.

Cervical lordosis in the general population has a very wide range in both sexes. Overall cervical lordosis was 37 degrees. Lower cervical lordosis (superior endplate of C4 to inferior endplate of C7) demonstrated an average of 16 degrees, and upper cervical lordosis was found to be 21 degrees.

No particular age group or sex was more prone to having lesser/greater lordosis.

Current literature is sparse and provides large ranges, different standards and variable methods for assessing standard cervical lordosis. Overall cervical lordosis is very variable amongst the sexes and age groups. We provide a standard set of values which help to provide the spinal surgeon with values to aim for when seeking to restore cervical lordosis.

Balloon kyphoplasty (BKP) is a minimally invasive treatment for vertebral fractures (VCF) aiming to correct deformity using balloon tamps and bone cement to stabilize the body. Patients with 1 - 3 non-traumatic acute VCF were enrolled within three months of diagnosis and randomly assigned to receive either BKP (N=149) or nonsurgical care (N=151). Follow-up was 2 years.

The mean SF-36 physical component summary (PCS) score improved 5.1 points (95%CI, 2.8-7.4; p<0.0001) more in the kyphoplasty than the nonsurgical group at one month, the primary endpoint of the study.

Kyphoplasty improved the PCS score by an average of 3.0 points (95%CI, 1.6-5.4; p=0.002) during the two-year follow-up. There was a significant interaction between treatment and follow-up time (p=0.003), indicating that the treatment effect over the year is not uniform across follow-up; a result from early improvement that persists in the kyphoplasty group whereas the nonsurgical group shows more incremental improvement over time.

Overall, patients assigned to kyphoplasty also had statistically significant improvements over the two years compared to the control group in global quality of life (EQ-5D), pain relief (VAS), back disability (RMDQ) and days of limited activity (within a two-week period).

There was no statistical significant difference between groups in the number of patients with adverse events or new VCF's over 24 months.

Compared to the control, BKP improved quality of life and reduced back pain and disability and did not increase adverse events including the risk of new vertebral fractures over 2 years.

Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has focused on VTE following joint arthroplasty their exists a gap in the literature examining the incidence of VTE in spinal surgery; with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited.

This survey, undertaken at the 2009 BASS Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery and to compare selections made by Orthopaedic and Neurosurgeons.

We developed a questionnaire based around eight clinical scenarios. Participants were asked to supply details on their speciality (orthopaedics or neurosurgery) and level of training (grade) and to select which method(s) of thromboprophylaxis they would employ for each scenario. Thirty-nine participants provided responses to the eight scenarios; complete details, including speciality and grade of those surveyed, were complied for 27 of the 39 questionnaires completed.

LMWH was the preferred pharmacological method of thromboprophylaixs selected 31% and 72% of the time by orthopaedic and neurosurgeons respectively. For each of the eight clinical scenarios LMWH and BK TEDS were selected more frequently by neurosurgeons than orthopaedic surgeons who elected to employ early mobilisation and mechanical prophylaxis. Neurosurgeons were more likely to employ more than method of thromboprophylaxis.

Thromboprophylactic selections differed between the two groups; Neurosurgeons preferred LMWH and BK TEDS whilst Early Mobilisation and Mechanical prophylaxis were the preferred methods of thromboprophylaxis amongst orthopaedic surgeons. Based on the results of this survey neurosurgeons more closely adhered to guidelines outlined by NICE/BASS.

To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity

Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence

24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up

Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices

Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%).

Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved.

Auckland City Hospital, Auckland, New Zealand.

To show that the spinous processes (SPs) increase in size with age.

To investigate the incidence of SP abutment, relationship to disc degeneration and age related kyphosis.

Describe patterns of SP neoarticulation in relation to back pain and intersegmental axial rotation and deformity.

We reviewed 200 Abdominal CTs, CT myelograms and 100 standing x-rays (age 18-90 years).

We measured SP size, interspinous gap, patterns of neoarticulation, disc height, lumbar lordosis and axial rotation.

We compared symptomatic and asymptomatic groups.

A 30-50% increase in SP size coupled combined with a loss of disc height leads to increasing rates of SP abutment after the age of 35 years. 30% of people over the age of 60 years have SP abutment.

There is a 15 degree increase in standing lumbar kyphosis with age.

Four patterns of SP neoarticulation are seen. Degenerative changes in the SP articulation increase by more than 80% in a symptomatic cohort.

Oblique SP articulation is 2.5 times more likely in symptomatic individuals and associated with a rotational intersegmental deformity.

Ageing is accompanied by SP enlargement and abutment, contributing to a loss of lumbar lordosis.

Patterns of neoarticulation and degeneration appear associated with back pain and rotational deformity.

To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery.

Retrospective

37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values.

Amount of perioperative blood transfusion, costs

14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case.

The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial.

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome.

Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A.

In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented

Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline.

Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

Several surgical options have been utilised to treat patients with back dominant lumbar disc disease. The purpose of our study was to compare the outcomes in patients who underwent lumbar fusion with an expandable interbody device (B-TWIN) using different surgical techniques (PLIF, TLIF or posterolateral screws alone)

Observational study, retrospective analysis of prospectively collected data. Patients underwent a single level lumbar fusion. Group A: PLIF with B-Twin cage; Group B: TLIF with B-Twin cage and unilateral pedicle screw fixation and Group C: bilateral posterolateral screw fixation alone.

Functional outcomes were assessed using: SF-36, Oswestry Disability Index (ODI), Distress and Risk Assessment Method scores (DRAM) and the visual analogue pain scores (VAS).

There were 32 patients, 24 female and 8 male. Average age was 45 (range 33-63). Average follow up was12 months (range 2-36). Level of spinal fusion was 2 L3/4, 11 L4/5 and 13 L5/S1. Mean hospital stay was 5.8 days.

VAS improved in all 3 groups A 5.83 – 5; B 8 – 4.83; C 5.71 – 2.3.

ODI improved in all 3 groups A 0.5 – 0.35; B 0.51 – 0.44, C 0.42 – 0.16.

There was no statistical difference on comparison of the three groups.

There were no operative complications. One patient broke her interdody device during a all in the first post-operative week requiring a subsequent procedure.

Lumbar interbody fusions can safely be performed using an expandable interbody device. Good functional outcomes can be achieved in the majority of well selected patients

Male retrograde ejaculation is a well-documented but rare complication of anterior approach lumbar spine surgery. Retraction of the soft tissues which encase the superior hypogastric plexus leads to dysfunction of the sympathetic control of the bladder neck sphincter. We postulated that similar nerve root dysfunction in females may lead to bladder problems and sexual dysfunction.

The Female Sexual Function Index Questionnaire was sent to 20 consecutive women who had undergone anterior spinal surgery by the senior author (GM).

Questionnaires were returned by 11 of the 20 subjects. 6 had undergone disc replacement surgery and 5 anterior lumbar interbody fusion. All procedures used an anterior retroperitoneal approach. The age range was 20 to 49 years (mean 40.2 years). There were no immediate peri-operative complications. The mean time since surgery was 4.9 years (range 3.1 to 5.8 years).

The Female Sexual Function Index is a validated questionnaire used internationally as the gold standard measure of sexual dysfunction in women. Urinary frequency and incontinence were also recorded.

9 women (82%) described a degree of post-operative sexual dysfunction with 7 (64%) recording urinary frequency and urge incontinence.

Although some sexual dysfunction may be expected from pre-existing conditions, we highlight this complication following anterior lumbar spine surgery in females. We plan to further investigate its incidence and possible resolution of symptoms after a prolonged period in a larger case series.

Competency levels of AOSpine members (Europe) based on whether or not they had undertaken a full 12 month fellowship in spinal surgery

Self-assessment questionnaire distributed to members (60 questions relating to: previous surgical training, fellowships and their nature, and both theoretical and practical competency amongst basic and advanced spinal conditions)

289 completed responses

Competency levels with(out) fellowship; differences in fellowship training; overall competence in spinal surgery as neurosurgeons versus those trained as orthopaedic surgeons. Competency defined as those able to deal with complications or able to perform without supervision.

28% (n=80) undertook a full 12 month fellowship

Notable differences between groups were identified (fellowship vs no fellowship): spinal deformity (58% vs 26%), cervical trauma (83% vs 59%), cervical stabilisation (78% vs 53%), lumbar and thoracic trauma (85% vs 57%) and anterior surgery (66% vs 41%) and its complications (46% vs 23%).

Interestingly of the whole group only 43% were competent in the actual practice of conservative management of spinal conditions.

There was no significant difference in theoretical knowledge or practical skills between orthopaedics surgeons and neurosurgeons.

Fellowship training is effective, but there are deficiencies in areas. In order to provide a routine and emergency service as a spinal surgeon, competency at relatively common procedures must be reached. Our data demonstrates a lack of uniformity in such competencies, and we believe efforts towards a formal curriculum for spinal training should be embarked upon.

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries.

By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?

Retrospective study

We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted.

The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°.

In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level.

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation.

This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up.

Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction.

Clinical measurement of rib prominence using scoliometer.

The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05).

This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique.

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane.

To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level.

Retrospective Study

200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane.

The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%).

As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity.

Coccygectomy, surgical excision of the coccyx, may be used to treat coccydynia, a chronic and disabling condition of the lowest part of the spine. It is a controversial and infrequently performed operation that many surgeons are reluctant to perform due to the risks of rectal perforation and infection. The criteria for patient selection for coccygectomy remain ill-defined. We present a single surgeon case series of 17 patients who underwent coccygectomy for chronic coccydynia.

This was a retrospective observarional case series analysis. Case notes of 17 patients who underwent coccygectomy from 1999 -2009 were obtained and analysed. We then carried out telephone survey for which only 15 patients were contactable. We used the Milton Keynes Orthopaedic Patient Satisfaction survey and the modified Oswestry low back pain disability questionnaire.

All patients had a two to three year history of coccydynia; 15 following trauma, one following a caudal injection and one following birth delivery. All patients had received between one and five lignocaine/methylprednisolone injections prior to coccygectomy, with documented initial symptom relief. All 17 patients had documented hypermobile sacro-coccygeal joints. Post-operative symptom relief varied between 60% and 100%, with all patients reporting that they would have their surgery again. Complications included three post-operative wound infections. There were no cases of rectal perforation. Coccygectomy for intractable coccydynia is sometimes the only option available. With good patient selection, including identification of a hypermobile joint with initial symptom relief following local injection, coccygectomy is a successful and safe treatment.

In this study we aim to establish which symptoms and signs are able to reliably predict the presence or absence of cauda equina syndrome.

Prospective collection of data was carried out over 10 months on all patients referred with suspected cauda equina syndrome(CES) to a single spinal unit. 28 patients were referred.

MRI was normal in 4 (14%) patients. 4 (14%) had disc prolapse causing CES and 3 (11%) had spinal metastatic disease. All patients with CES presented with low back pain, unilateral sciatica, urinary dysfunction (painless retention 2, incontinence 2), altered perianal sensation and abnormal anal tone. 1 described constipation. Of patients without CES or malignancy 21 (100%) complained of low back pain, 19 (90%) sciatica (15 unilateral, 4 bilateral), 12 urinary dysfunction (incontinence 5, reduced sensation 3, painless retention 2, urgency 1, terminal dribbling 1) and 5 described altered bowel habit. 7 (33%) exhibited altered perianal sensation and 1 (5%) abnormal anal tone.

The patients with spinal metastases all described back pain but no sciatica. 2 had urinary retention and constipation with 1 having abnormal perianal sensation and anal tone.

This study suggests abnormal anal tone (sensitivity 1.0, specificity 0.95) and altered perianal sensation (sensitivity 1.0, specificity 0.67) are the most reliable predictors of CES. Thorough clinical examination is essential. Back pain with bladder and/or bowel dysfunction without sciatica should raise the suspicion of malignancy.

Surgical management of symptomatic lumbar degenerative disc disease (DDD) currently consists of fusion or implantation of a first generation total disc replacement (TDR). This study is the first to evaluate an elastomeric one-piece TDR in a 50-patient European study.

Fifty patients with single-level, symptomatic lumbar DDD at L4-S1 who were unresponsive to at least 6-months of non-operative therapy were enrolled in a clinical trial of a viscoelastic TDR (VTDR) at three European sites. Patients were assessed clinically and radiographically at 6 weeks, 3 and 6 months, and 1 and 2 years. Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were used to assess clinical outcomes.

Twenty-eight males and twenty-two females were enrolled in the study. The average age of patients was 39.7 (23 to 61). The operative level was L4/L5 in 13 patients and L5/S1 in 37 patients. There were no intra-operative complications. Quantitative radiographic assessment indicates that the VTDR restores and maintains a physiologically appropriate disc height and angle, while providing range of motion and translation similar to those provided by the natural disc. Mean ODI scores decreased from 48% pre-operatively to 25% at two years follow up. Mean VAS low back pain scores decreased from 7.1 cm pre-op to 3 cm at two years. Median scores indicate that half of the patient population has ODI scores below 13% and VAS back pain scores below 0.5 cm. Clinically and radiologically, this elastomeric disc is performing satisfactorily, and the causes of clinical failures can be more readily identified.

Department of Epidemiology, ASL RM/E, Rome, Italy

School of Health and Social Care, University of Teesside, Middlesbrough, UK

Faculty of Health, Staffordshire University, Stoke on Trent, UK

Orthopaedic and Trauma Department, “Tzanio” General Hospital of Piraeus, Greece

University of Medical Sciences, Poznan, Poland

Department of Orthopaedic Surgery, Saitama Medical University, Kawagoe, Japan

Thriasio General Hospital, Athens, Greece

To evaluate the efficacy of bracing in adolescent patients with AIS.

Cochrane systematic review

The following databases were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINHAL and reference lists of articles. Extensive hand searching of grey literature was also conducted. RCT's and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces were included. Two review authors independently assessed trial quality and extracted data.

Two studies were included. There was very low quality evidence from one prospective cohort study including 286 girls¹indicating that braces curbed curve progression, at the end of growth, (success rate 74%), better than observation, (34%) and electrical stimulation (33%). Another low quality evidence from one RCT with 43 girls indicated that a rigid brace is more successful than an elastic one (SpineCor) at limiting curve progression when measured in Cobb degrees². No significant differences between the two groups in the subjective perception of daily difficulties associated with brace wearing were found.

There is very low quality evidence in favour of using braces, making generalization very difficult. The results from future studies may differ from these results. In the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes as well as measures such as Cobb angles. RCTs and prospective cohort studies should follow both the SRS and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies.

To quantify the duration of symptoms and the treatment modalities employed prior to surgery in patients undergoing lumbar and cervical nerve root decompression and to assess the evidence of these non-surgical treatments.

Pre- and post operative questionnaires completed by consecutive patients.

514 people undergoing consecutive cervical or lumbar nerve root decompression between March 2007 to October 2009.

Pre-operative severity and duration of pain, functional limitations and treatment received. Post-operative pain severity and change in functional limitations.

Evidence in the literature for efficacy of treatment modalities employed.

Mean duration of pre-operative symptoms was 23 months (range 1 to 360). 91% took regular medication for pain, 83% received one or more physical therapy, 24% received injection therapy.

There was improvement in both pain scores (mean pre-op 7.3; post-op 3.0) and 78% of the commonly reported functional limitations, walking, sleep and work.

We found extremely limited evidence to support the other treatment modalities employed.

Patients spend many months unnecessarily in pain, consuming considerable resources and may suffer significant side effects from ineffective treatment for pain emanating from nerve root compression. Surgical nerve root decompression relieves pain and restores function. Despite this a specialist opinion is often delayed. Early referral for specialist opinion is almost certainly more humane, cost effective, and time-limits the journey on the not so magic roundabout.

To report on the management of a patient with grade 1 holocord pilocytic astrocytoma and scoliosis.

Case report of a rare spinal cord tumour and a management of the scoliosis.

An 11 year boy complained of gradually worsening neck, back pain and pain in all limbs. This was accompanied by unsteadiness, weakness of lower limbs and bed wetting of recent onset. There was a family history of spinal cord tumour.

Examination revealed signs of spinal cord compression and a left thoracic scoliosis. Magnetic resonance imaging showed an intra-medullary tumour extending through the spinal cord and syrinx formation.

He underwent T1-3 approach for drainage of syrinx, biopsy of tumour and laminoplasty with plates. He was started on chemotherapy for 14 months. During this period a syringo-peritoneal shunt was inserted. There was further growth of the tumour and neurological deterioration. He subsequently underwent T8-L1 laminoplasty, debulking of tumour and insertion of dual diameter growing rods.

There has been no significant neurological deterioration. There was good correction of the scoliosis with Cobb angle reducing from 50 to 15 degrees. Lengthening of growing rods has been done 4 times with good length achieved.

Excision of tumour and growing rod insertion (not previously reported) is a good way of controlling neurological symptoms and the scoliosis in this rare spinal cord tumour.

To assess radiological fusion rates in posterolateral fusions using SiS-CaP.

Retrospective, radiological follow-up study.

Single surgeon series of 76 consecutive patients were evaluated, in a regional spinal unit. All patients had clinical and radiological (MRI) spinal canal stenosis secondary to degenerative spondylosis or spondylolisthesis. Surgery consisted of instrumentation, decompression and meticulous preparation of the posterolateral graft bed by removal of all soft tissues posterior to the inter-transverse membrane and decortication of transverse processes (TPs). SiS-CaP putty was injected into this gutter and moulded around the instrumentation. Good quality, well prepared bone chips from the posterior decompression were seeded into the putty. Patient radiographs were reviewed at 3-6 months, 1 year and 2 years.

Radiographs were assessed using a protocol to examine granularity, bone formation and evidence of pseudarthrosis, based upon previously reported literature ¹ and our personal experience.

Of the 76 patients, 26 were excluded. M:F was 21:29. Mean age was 58yrs. Average number of motion segments fused per case was 2.2. There was one pseudarthrosis with metalwork fracture, and thus a total fusion rate of 98%. In addition, one patient had scanty bridging of TPs, and one patient had lucency around the S1 screws.

SiS-CaP, as a bone graft substitute in posterolateral instrumented fusions, gives comparable results to published fusion rates using autologous iliac crest grafting and/or Bone Morphogenic Protein ². Moreover, it avoids the associated morbidity of iliac bone harvest.

To determine the current practice of scoliosis surgery in the UK.

A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence.

Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows.

All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case.

This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature.

The aim of most new implants for cervical disc replacement is to maintain or restore function. The Dynamic Cervical Implant (DCI(tm), Paradigm Spine) aims at combining the advantages of the gold standard fusion technique with the motion preservation philosophy. DCI has a limited motion: it works like a shock absorbing spring and may help to slow down adjacent segment degeneration.

Between 2007 and 2009 we selected 79 patients aged 32 to 73 years for treatment with DCI at either one or two levels (10 patients). Indications were radiculopathies (n=45), axial pain (n=4) or spondylotic spinal stenosis (n=30) with out chronic myelopathy. Patients are followed up at 3, 6, and 12 months after surgery.

Disc surgery was performed at C3/C4 (n=2), C4/5 (n=6), at C5/6 (n=43), C6/7 (n=37) and at C7/T1 (n=1). In flexion/extension radiographs motion rapidly increased after surgery. However, 5 of 19 treated levels were fused (seen at 6 or 12 months). After implant footprint was changed and larger sizes were provided only 2 of 67 segments fused. Still 96% of the patients rated their clinical result as excellent or good. There were no implant related complications or revision surgery.

Disc replacement with DCI is a new strategy that is positioned in between anterior cervical fusion and disc prosthesis. Clinical results are as good as in anterior cervical fusion. Adjacent segment protection must be judged in future follow-ups. We were able to show that the change of implant footprint has significantly reduced fusion rate.

To analyse the pain distribution in the acute and chronic phase following thoracolumbar fractures.

Prospective observational study

39 patients with fractures between T11 and L2, with no neurological deficit, were treated conservatively. Strict inclusion and exclusion criteria were applied. All had X-rays and MR imaging (whole spine) at post-injury and one-year follow-up.

The patients documented their pain distribution using pain drawing, along with 10 other domains of pain and functional outcomes for a period over 12 months. The pain distribution was analysed. The association of distal pain distribution to - other associated injury, resultant kyphosis, Pre-existing or increase in disc degeneration at the lower non-injured disc levels – were analysed and reviewed

The most common site of the pain distribution in both the acute (90%) and chronic phase (97%) was distal to the fracture (regions - iliac crest, lumbosacral junction and buttock). Factors mentioned above that could be related to distal pain distribution did not show any significant correlation (P>0.5) with different domains of pain outcome.

Some of the commonly believed reasons for distal pain distribution like resultant kyphosis and associated disc/facet pathologies were not supported by our study findings. The distal pain distribution corresponds to the scelerotomal referred pain mapping, which could be the probable explanation. Thoracolumbar pathologies could be the source of pain in patients complaining of low back symptoms. Distal pain distribution of spine pathologies should not be attributed as functional.

To describe a modification of the existing technique for C2 translaminar screw fixation that can be used for salvage in difficult cases.

Bilateral crossing C2 laminar screws have recently become popular as an alternative technique for C2 fixation. This technique is particularly useful in patients with anomalous anatomy, as a salvage technique where other modes of fixation have failed or as a primary procedure. However, reported disadvantages of this technique include breach of the dorsal lamina and spinal canal, early hardware failure and difficulty in bone graft placement due to the position of the polyaxial screw heads. To address some of these issues, a modified technique is described. In this technique, the upper part of the spinous process of C2 is removed and the entry point of the screw is in the base of this removed spinous process.

From October 2008 to March 2009, 6 patients underwent insertion of unilateral translaminar screws using our technique. The indications were: basilar invagination(three cases), C1/C2 fracture (two cases), tumour (one case). Age varied from 22 to 81 years (mean 48 years).

All patients had post-operative x-ray and CT scan to assess position of the screws. Mean follow-up was 6 months.

The screw position was satisfactory in all patients. There were no intraoperative or early postoperative complications.

Our modification enables placement of bone graft on the C2 lamina and is also less likely to cause inadvertent cortical breach. Because of these advantages, it is especially suitable for patients with advanced rheumatoid arthritis with destruction of the lateral masses of C2 or as part of a hybrid construct in patients with unilateral high riding vertebral artery. This technique is not suitable for bilateral translaminar screw placement.

To evaluate the current biomechanical and clinical evidence available on the use and effectiveness of lumbar interspinous devices

Literature review

A PubMed search was done using the following key words: interspinous implants, interspinous devices, interspinous spacers, dynamic stabilization, X-stop, Coflex, Wallis, DIAM. The abstracts of all the articles were reviewed. Further critical analysis was done of the relevant articles. Special emphasis was given to those articles pertaining to biomechanical and clinical results.

A total of 50 articles were found, 18 of them also related to the effect of spacers on the biomechanics of the spine. 25 articles were on the X-stop device. However, level I evidence is lacking. Only two prospective randomized controlled trials have been done and these were on the X-Stop device.

Analysis of current evidence suggests a potential beneficial effect of lumbar interspinous spacers in select group of patients. However, further level I evidence is required to justify their widespread use for all the proposed indications. The results of the ongoing trials are keenly awaited.

Non-dysraphic intradural spinal cord lipomas are very rare lesions and the management remains controversial. We present our experience with five cases, review the literature and propose guidelines for their management

The case notes of the patients were retrospectively reviewed. An extensive literature search was done, and the relevant articles were analyzed.

Between January 2004 and April 2009, we operated on five cases of non-dysraphic intradural spinal cord lipomas. The age at presentation ranged from 17 years to 52 years (mean 32.2). Minimum follow up was 6 months and maximum follow up 5 years. All patients underwent decompression with a laminectomy/ laminoplasty and debulking. The dura was primarily closed in one patient.

All patients had regular clinical and radiological follow-up with serial MRI scans.

Neurological improvement was noted in all patients. There was significant residual tumour on the MRI scan in all patients. Guidelines for management were formulated on the basis of our experience and literature review.

The aim of surgery should be adequate decompression with preservation of neural structures. Aggressive debulking should be avoided. Onset of any neurological symptoms/signs, bowel or bladder symptoms or intractable local symptoms should be an indication for surgery.

We have studied two matching cohorts of patients treated by Dynesys flexible stabilisation with and without hydroxyapatite (HA) coating of the pedicle screws.

From our series of 570 Dynesys procedures, we studied patients with HA coated screws with a minimum one year follow-up.

Patients were entered prospectively and followed up at 6 weeks, 3, 6, and 12 months and annually thereafter. Plain radiographs were obtained annually. 58 patients (26 males, 32 females, mean age 55 years at surgery) underwent Dynesys stabilisation with HA coated screws. The data was compared with 69 patients who underwent Dynesys stabilisation with non-coated pedicle screws between 2004 and 2006 (26 male, 53 female, mean age 54 years). Outcome measures were screw loosening, breakage, implant removal or revision.

A total of 320 HA coated pedicle screws were inserted. 12 patients were lost to follow-up. 2 patients underwent subsequent level extension, and 2 had their implants removed. There were four screw breakages in three patients, all affecting S1 screws. There was no evidence of screw loosening in any patient. In the non-HA coated group 354 pedicle screws were inserted. 5 patients required revision or subsequent surgery. 12 patients had screw loosening and required implant removal. There was a significant improvement of anchorage of the HA coated screws.

Change to HA coating was investigated because of high loosening in plain screws. The improvement has been highly significant. Flexible stabilisation is a better model than fusion because the implant remains under constant load.

Disclosure: The authors did not receive any outside funding in support of preparation of this work.

To evaluate and describe the plain radiographic changes observed with time in fusions using SiS-CaP. We describe, for the first time, 4 stages of bone substitute fusion mass (BSFM) radiographic appearance in relation to time post-op.

Retrospective, radiological evaluation.

Over 200 plain radiographs were evaluated. 70 consecutive fusions for degenerative spinal stenosis were included, in all cases performed by the same surgeon using the same operative technique. Follow-up was from 3 months to 2 years post-op.

Radiographs were evaluated for the presence or absence of SiS-CaP granules, bone formation and for evidence of pseudarthrosis.

Trends were seen within the BSFM with respect to time. At 6-12 weeks post-op a ‘homogenous granular stage’ indicates the presence of the unchanged SiS-CaP.

At 12 weeks, small pockets appear within the BSFM in the ‘vacuolation stage’, indicating bioresorption of the graft. Vacuoles become increasingly radio-opaque indicating bone proliferation during the ‘homogenous lamellar stage’. At variable time between 6 months and 2 years, the BSFM becomes encapsulated in the ‘cortication stage’ visible as a sclerotic rim around the BSFM.

We have seen a clear trend in the behaviour of the fusion mass in this case series. The radiological stages we have described above can be closely correlated with previously reported in-vitro and in-vivo studies looking at the micro-function of SiS-CaP. We hope that this description will help to judge the progress of graft incorporation and fusion. Further study of inter and intra-observer correlation will be required.

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

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.

We have examined how many and which potential complications (PCs) are recorded on the consent form by a group of consultant surgeons performing common spinal procedures - anterior cervical discectomy and fusion (ACDF) and posterior lumbar discectomy and/or medial facetectomy (PLD).

Email survey

Consultant spinal surgeons performing ACDF and/or PLD practicing in Southwest England

Identification of the PCs each surgeon listed on the consent form for the specified procedures.

There were 23 responses from 28 Consultant surgeons approached. 21 surgeons performed both ACDF and PLD, 2 performed only PLD. Surgeons quoted 5 to 17 (mode 10) PCs for ACDF and 4 to 15 (mode 13) for PLD. These did not necessarily represent the most common or most dangerous PCs recorded in the literature^1,2. Small difference in PCs mentioned by Neurosurgeons and Orthopaedic surgeons was seen (ACDF mode: 12vs10, PLD mode: 12vs13). There was a strong correlation between the number of PCs recorded by surgeons for ACDF and PLD.

We have found a wide variation in consenting practice amongst a group of surgeons performing common spinal operations. Issues of consent are common causes of formal complaints and potential litigation, causing anxiety for both patient and surgeon. A more homogenous consent process, employing objective measures where possible, may help reduce this burden and may be achieved by setting a national standard.

To review blood transfusion practices during elective spinal surgery procedures

Prospective clinical audit

All patients who underwent elective spinal surgery between January 2009 and March 2009.

Crossmatch: Transfusion ratio (C: T ratio); Transfusion index (TI) (Evaluates cost-effective crossmatch). British Haematological society standards are C:T ratio= 2.5:1 and TI>0.5

Data was collected from electronic records of blood bank, pathology system (NOTIS) and review of patient notes. A total of 194 patients underwent elective spinal surgery in our unit. (Cervical spine = 15, Thoracic spine = 3, Vertebroplasty = 10, Lumbar spine = 142, Deformity = 31, other = 8). Of these, 62 patients had 197 blood products crossmatched but only 37 units were used. C:T ratio in lumbar spine surgery was 22:1. However C: T ratio in cervical spine procedures, thoracic spine and deformity correction were 6:1, 11:0 and 4:1 respectively. TI was <0.5 in all procedures except deformity surgery (TI=1).

Over- ordering of blood products is still common in spinal surgery as routine blood transfusion may not be required in most elective procedures. Therefore implementing Electronic Issue (EI) of blood products for elective spinal procedures for non deformity procedures can be a cost effective and safe practice.

Traditionally, spinal surgeons placed radiographs on viewing boxes in a manner (PA) to replicate the view they would have at surgery. The introduction of digital Picture Archiving and Communications System (PACS) appears to have had marked impact upon this convention. Some Units have the ability to lock digital radiographs such that they are always viewed in the same manner and cannot be reversed.

Following ‘two near misses’ we carried out a survey to confirm the previous practice with radiographs; to ascertain the current practice with PACS and to find out whether the variation in practice could lead to clinical mishaps and harm to patients.

Questionnaires were completed by practicing spinal surgeons.

Previous and current practice of viewing radiographs. Either actual or potential wrong side surgery. Opinions as to whether a single convention was important were recorded.

78 % Spine surgeons used to flip radiographs over prior to introduction of PACS. With PACS, 56 % spine surgeons flip the radiographs over in clinic and 72 % in theatre so to resemble viewing spine from behind. 56% Surgeons had nearly operated on the wrong side of the spine while 94 % have seen or heard of a patient operated on the wrong side. 72 % Spine surgeons agree that the radiographs should be flipped over so as to resemble the spine as viewed intraoperatively.

There is need for a single convention in spine surgery to view radiographs to avoid potential clinical mistakes.

To assess adverse events related to XLIF approach in lumbar degenerative disease.

Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients.

Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited.

Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%).

2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique.

This did not require Ethics approval and there was no grant or industry support for the above.

To determine factors such as age, sex and curve severity in patients with idiopathic scoliosis presenting for the first time to a spine deformity clinic.

A prospective study at a regional spine clinic.

Patients with idiopathic scoliosis presenting for the first time to the scoliosis clinic were entered into a database recording information such as age, symptoms, severity of scoliosis as measured by the Cobb angle (CA), spine rotation measured by Scoliometer, geographical region, person detecting the curve, neurological findings etc. The study period was from June 2008 to September 2009 inclusive.

Fifty consecutive patients with all required information in the database were included in the analysis. All eligible patients were not entered due to logistical reasons.

13 males and 37 females, average age 13.96 (range 1 to 23). 68% were unhappy with the shape of their back, 48% presented with significant pain and 32% had both. The mother first saw the scoliosis in 52%, the rest were seen by either the patient, friends or doctors.

36 were single curves with a mean CA of 34 degrees ranging from 10 to 80 degrees. 52% of patients presented with a curve of 40 degrees or more. 14 had double curves. None of the patients were found to have any abnormal neurological findings.

There are few epidemiological studies in the recent literature. This data was not previously available in our region and initial presentation with a severe curve is a worrying trend which triggered this study.

The study is been conducted to compare the outcome of pedicle screw fixation in dorsolumbar fractures by long segment fixation and short segment fixation with a screw in fractured vertebra.

Study includes the consecutive patients of dorsolumbar fractures treated by either long segment or short segment fixation. Twenty patients were included in each category. Patients with or without neurological deficit were included. Patients with single fractured vertebra only were included.

Patients with single level dorsolumbar fracture were subjected to detailed radiological analysis preoperatively by measurement of height loss and kyphosis angle of fractured vertebra. Detailed neurological status was recorded. During the fixation the pedicle screw was inserted in less affected pedicle of fractured vertebra and decompression if needed was done by hemilaminectomy of other side. Bone graft

Postoperative kyphosis correction and restoration of height was calculated in both the groups. At 3 months, 12months and 24 months the maintenance of corrected kyphosis and restored height was recorded.

Neurological examination to record the effect of surgical intervention on neurological recovery was recorded at every examination.

All the patients had satisfactory outcome. The loss of correction in both the groups was comparable.

The treatment allows easier postoperative nursing and early mobilization of the patient. Segmental fixation with screws at the level of the fracture offers improved biomechanical stability. It allows additional fixation points that may aid in fracture reduction and kyphosis correction. It also reduces the duration of surgery, blood loss as well as cost of implant without significant compromise on outcome.

Pedicle screw at the level of fracture in short segment fixations provides added stability, better postoperative maintenance of corrected kyphosis at reduced cost of implant.

The study was conducted to review the outcome in cases of anterior expandable interbody cages inserted through a posterior only approach. Cases selected were the anterior cage insertion and posterior stabilization patients managed by posterior only approach.

Study includes the patients of various pathologies requiring 3 column support. Twenty patients were included in study. Pathology in 9 patients was tuberculosis, trauma in 3, tumours in 3, metastasis in 3 and deformities in 2patients. Patients with or without neurological deficit were included.

Cases were carefully assessed and patients with single level involvement were included as more then single level involvement required more extensive exposure and possible nerve root sacrifice. Detailed neurological status was recorded. The surgery was performed in prone position and after posterior stabilization by pedicle screws the extracavitatory approach was used to insert the expandable cage. In cases of suspicious pathologies the samples for histopathology and staining were collected.

Morbidity, mortality blood loss, surgical time, complications, outcome of surgery were compared with historical controls of front and back surgery.

The insertion of cages from posterior approach was feasible in all carefully planned cases. None of the patients had problem related to implant in form of cage displacement. All the patients had satisfactory outcome.

Posterior stabilization of spine with expandable cage insertion from posterior approach saves the operating time, spares the additional surgical incision and blood loss without compromising the outcome. In carefully planned surgeries it gives excellent results irrespective of etiology.

Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases.

Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined.

Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007).

Procedures were bilateral, left or right.

126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected.

There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse.

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making.

Retrospective cohort analysis

120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88).

We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making.

Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment.

Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected.

To evaluate functional and oncological outcomes following resection of primary malignant bone tumours.

Primary malignant tumours of the sacrum are rare, arising from bony or neural elements, or bone marrow in haematological malignancies.

Management of these lesions is dictated by anatomical considerations and the behaviour of tumours. The three key issues which arise are the adequacy of tumour resection, mechanical stabilisation and the need for colostomy.

A retrospective review of the surgical management of primary malignant sacral tumours from 2004 - 2009.

The study included 46 patients (34 males, 12 females) with an average age of 49 (range 7 – 82). Median duration of symptoms before presentation was 26 months.

10 patients had inoperable tumours at presentation. 6 patients had chemotherapy. 2 patients opted for palliative radiotherapy. 1 patient was unfit for surgery.

25 patients (54%) underwent surgical resection. 8 underwent instrumented stabilisations with fibula strut graft vs. 17 uninstrumented.

Colostomy was performed in 10 patients (40%). Mean follow post-operatively was 19.0 months.

Wound healing problems were present in 5/25 (20%). There was no difference in infection rates between definitive surgery with and without colostomy. Mechanical failure of stabilisation was noted in 75%. There was one peri-operative death.

Local recurrence occurred in 12%(3/25) of operated patients although follow-up period was noted to be short.

Mechanical stabilisation for extensive lesions in the sacrum are particularly challenging in tumour surgery. Despite radiological failure in 7/8 instrumented stabilisations, patients were relatively asymptomatic and only 1/8 required revision stabilisation surgery.

Ethics approval: None: Audit Interest Statement: None

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro)

48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery.

Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated.

25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES).

Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery.

To assess the effectiveness of unilateral sublaminar and concave rib tethering with convex rib resection through the period of peak growth in lambs.

Morphometric growth data from 10 experimental Scottish Blackface sheep were compared to those from 5 control animals (no intervention) over 12 months.

Standardized AP and Lateral radiographs were taken before and at monthly intervals after scoliosis creation. The Cobb angle was measured in the coronal and sagittal planes. Rotational mal-alignment was assessed by axial CT 7 months post surgery.

In the supine position the control animals had no coronal plane deformity and a mean 5° lordosis (T4-T12). These figures did not alter with growth (doubling of body weight). Tethering (at age 5 weeks) produced an immediate scoliosis of 22±11° and a lordosis of 24±8° (means(sd). The degree of scoliosis was maintained over 7 months (at 20°) but lordosis increased (to 59±11°, p<0.01). There was an associated change in vertebral rotation. Surgery had no influence on rate of growth or animal development.

Two animals died from Clostridium associated enterocolitis. There were no deaths associated with the surgical intervention.

This ovine model gives a progressive spinal deformity in the sheep but primarily in the sagittal plane. This fact should be considered in studies designed to evaluate the effectiveness of surgical implants.

Northumbria Healthcare NHS Trust, Ashington, UK

To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain.

Prospective study

23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan.

Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment).

The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23).

Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB.

To determine if the use of high density implants (i.e. high proportion of pedicle screws relative to number of spinal levels involved) causes significant loss of thoracic kyphosis and its effect on sagittal balance in adolescent idiopathic scoliosis.

Retrospective analysis of pre and post-operative radiographs to assess sagittal balance and C7-L1 kyphosis angle.

17 patients (16 females, 1 male). All right sided single thoracic curves. All surgery performed by single surgeon (Senior author, ED)

Comparison of pre and post operative sagittal balance and C7-L1 kyphosis angle. Assessment of implant density (i.e. proportion of pedicle screw relative to number of spinal levels involved in correction).

9 patients demonstrated improved sagittal balance following surgery. There was no significant difference (p value 0.83) between the pre and post op C7-L1 kyphosis angle. Mean angle pre op 28.9 (95% CI 20.3 to 37.5). Mean angle post op 29.6 (95% CI 22.2 to 37.0). No correlation identified between sagittal balance correction and kyphosis angle. Metal density ranged from 79-100%.

Although the sample size in this series is modest, high density implants do not significantly affect the kyphosis angle in the operative management of adolescent idiopathic scoliosis in the thoracic spine.

Magnetic Resonance Imaging (MRI) is the cornerstone investigation for cervical disc disease (CDD). However, MRI changes suggestive of CDD are found in people above forty, even in asymptomatic healthy individuals [1].

Mere presence of MRI changes of CDD does not exclude the presence of concomitant extra-foraminal pathology.

No study design.

We present here a series of three cases where use of ‘high resolution ultrasound’ has allowed accurate diagnosis of concomitant extra-foraminal pathology in patients with MRI-proven CDD. The three cases were acute neuropraxia of aberrant C5 nerve root, anterior interossous nerve compression due to pseudo-aneurysm of brachial artery and ‘acute brachial neuritis’ respectively.

No outcome measure.

Use of diagnostic high resolution ultrasound revealed accurate diagnosis of concomitant extra-foraminal pathology in all three cases. The cases with acute neuropraxia and acute brachial neuritis recovered with conservative treatment. Pseudo-aneurysm was treated successfully with surgery.

High resolution ultrasound of the brachial plexus and peripheral nerves may be useful in following scenarios to identify an extra-foraminal pathology: (1) when symptoms and signs are out of proportion to the MRI findings of CDD; (2) when there is obvious discordance between MRI and nerve conduction findings; (3) where an entrapment neuropathy is suspected but the site of nerve lesion cannot be located.

To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse.

Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise.

80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is

the crossed straight leg raise. The straight leg raise has not been shown to have high validity

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis.

A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy.

Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%.

VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction.

Spinal Biomechanics Lab, Baylor College of Medicine, Houston, Texas, USA

Documenting the patterns and frequency of collapse in non-operatively managed spine fractures, using a motion analysis software.

Retrospective analysis of prospective case series

105 patients with thoracic or lumbar fractures, were neurologically intact, and treated non-operatively for the ‘stable’ injury at our unit between June 2003 and May 2006. The mean age of the cohort was 46.9 yrs

Serial radiographs (mean 4 radiographs/patient; range 2 – 9) were analysed using motion analysis software for collapse at the fracture site. We defined collapse as a reduction of anterior or posterior vertebral body height greater than 15% of the endplate AP width, or a change in the angle between the inferior and superior endplates > 5°.

The changes were assessed on serial radiographs performed at a mean of 5.6 mo (95% CI 4.1 – 7.1 mo) after the initial injury. 11% showed anterior collapse, 7.6% had posterior collapse, 14% had collapse apparent as vertebral body wedging, and 17% had any form of collapse. ODI scores were obtained in 35 patients at the time of the last available radiograph. There were no significant differences in ODI scores that could be associated with the presence of any form of collapse (p > 0.8 for anterior collapse; and p = 0.18 for posterior collapse).

This pilot study with the motion analysis software demonstrates that some fractures are more likely to collapse with time. We hope to carry this work forward by way of a prospective study with a control on other variables that are likely to affect the pattern and probability of post-fracture collapse, including age, bone density, vertebral level, activity level, fracture type.

The purpose of our study is to assess the degenerative changes in the motion segments above a L5S1 spondylolytic spondylolisthesis, and to analyse the factors that contribute towards a retro-listhesis in the segment immediately above the slip.

Prospective radiographic case series

38 patients with a symptomatic L5S1 spondylolytic spondylolisthesis, with a mean age of 52.8 yrs (95% CI 47.2 – 58.4). 55.3% (n = 21) were females and 44.7% (n = 17) males. 58% (22) had grade 1 and 42% (16) grade 2 slips.

Plain radiographs: Lumbar lordosis, slip angle, sacral slope, grade of the slip, and retro-listhesis at L45. MRI scans: facet angles at L34 and L45, facet degenerative score at L34 and L45 (cartilage and sclerosis), disc degenerative score at L45 and L5S1 (Pfirrmann).

The Pfirmann disc score for L45 was 2.75 and L5S1 4.4 (p < 0.0001); the mean facet angle at L34 50.9° and L45 57.9° (p = 0.001) and the facet score at L34 was 8 and at L45 was 10.5 (p = 0.0001). 29% (11) demonstrated a retrolithesis at L45. Analysing the effect of these factors on the causation of retro-listhesis at L45 (table) the slip angle and L45 disc degenerative score were the only factors that predicted a retro-listhesis.

There is a cascade of degenerative changes involving both the disc and the facet joints at the levels above a spondylolytic spondylolisthesis. The degenerative changes at the L45 disc and a higher slip angle predict a retro-listhesis at the level above the slip.

To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre.

Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank.

26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work.

Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.

Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain.

We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5.

Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons.

Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing.

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

224 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006-2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Among 224 patients 13 (5.8%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11-40). 84.6% (n=11) patients were female and 15.3% patients were male. There was varying severity of curve patterns. We have noted two lumbar/thoraco-lumbar curves (Lenke 5), King Type I-6, King Type II-2 and three King Type III curves. All scoliotic deformities were non-structural. Bilateral pars defect was noted in nine (69%) patients.

Previous studies (Fisk et al, 1978; Mau H 1981) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al.). Our study reveals the incidence of pars defect in AIS to be 5.8 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

In major procedures like scoliosis surgery, parents are often asked to sign the consent on behalf of children because of the pretext that minor may have limited understanding and judgement about the procedure. Scoliosis surgery for patients with AIS is mainly indicated for cosmetic or psychological reasons.

We audited our practice in the department to collect information on the current consent practices involving the minor patients undergoing scoliosis surgery.

We also have conducted a questionnaire survey of the various spinal units in UK to assess their practice in this regard.

Forty-two consent forms (28 patients; multiple procedures in some patients) and case notes of patients between 12 and 16 years undergoing scoliosis surgery were reviewed. We have contacted 12 spinal deformity correction units and 11 spinal trauma units across UK over telephone to assess the current consenting practice as well.

9.5% (n=4) patients signed there own consent forms. Except in one case explanation of risks were documented in detail. Except two units (18%) offering the minor patient to sign their consent, parents are usually asked to sign consent on their behalf in majority (10/12) units. Seven out of the twelve spinal units use standard NHS or department of health consent forms. Few units have their own consent form with some alterations or additions.

There is no specific age when a child becomes competent to consent to treatment: It depends both on the child and on the seriousness and complexity of the treatment being proposed. However, it is still good practice to encourage competent children to more involved along with their families in decision-making.

To evaluate the patient experience of patients referred to the ESP Orthopaedic Triage Service. To identify the demographic data of the patients

To evaluate patients' expectations and satisfaction of the service

A prospective audit of 50 new patients to the ESP service in Mountain Ash General Hospital and Prince Charles Hospital

The audit was carried out over a 3 month period between December 2008 and February 2009.

Patients were asked to anonymously complete a survey following their appointment. Data was collated independently and analysed with descriptive statistics.

Patients referred to ESP service

Self administered satisfaction survey.

Mean age range 40-59 yrs (range 20 -70yrs). 50% >1 year duration of symptoms.

94% of patient's surveyed rated the service provided as good - excellent. 88% of patient's reported that they were happy to be assessed by the ESP.

96% of patients surveyed agreed they were able to discuss their treatment openly with only 10% preferring to see a Doctor.

The ESP service in Cwm Taff Health board achieves a high level of patient satisfaction.

Research literature suggests sub classification of LBP may improve clinical outcome. Audit aim is to evaluate the outcome of treatment pathways according to sub classification.

Patients had standardised assessment and completed Oswestry Disability Index (ODI) and Hospital Anxiety and Depression Scale (HAD) following assessment and on discharge.

Patients were subgrouped into; non specific LBP, radicular pain, LBP with high psychosocial indicators. Patients were allocated to 3 treatment pathways; individual treatment, functional Back class, back care programme.

200 adult patients referred to physiotherapy for low back pain. Exclusion criteria; red flag presentation, patient requiring advice only (n=38).

Pre treatment and post treatment HAD, ODI

Of 162 patients Individual treatment, 87 (40%)Functional Back Class, 41 (19%)

Back Care Programme, 34 (16%).

Each pathway demonstrated a clinically significant change in outcome measures. Patient's achieved an average change of between 11 – 17% dependant on pathway.

This suggests that the sub classification criteria used allowed the correct pathway choice for patients conditions.

Establish the positive predictive value of clinical examination predicted radicular level to MRI.

To identify the value of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) assessment tool in the assessment of patients presenting with radicular symptoms of lumbar spine source.

8 patients attending the ESP Orthopaedic triage service, presenting with radicular pain in which MRI is clinically indicated.

Prospective study on patients attending ESP Orthopaedic triage service

Patients were clinically examined, both parts LANSS score was completed.

Following the assessment a radicular level was selected.

Following MRI the results were compared.

Positive predicted values (PPV) for clinical examination and sensitivity and specificity of a LANSS score>12 was calculated.

LANSS score

MRI report.

PPV of 75% of therapist predicted level being same level or adjacent level to MRI stated level.

66% specificity and 100% sensitivity of patients in study with LANNS>12 having MRI evaluated radicular nerve root compression.

This pilot suggests that clinical examination and the LANSS score is useful in establishing the presence of radicular nerve root compression. This evidence supports the need for further research.

School of Mechanical Engineering, University of Birmingham, Birmingham, UK

This study investigated the effects on friction of changing the dimensions of a ball-and-socket Total Disc Arthroplasty (TDA).

A generic ball-and-socket model was designed and manufactured based on the dimensions and geometry of a metal-on-metal Maverick (Medtronic, Minneapolis, USA) device. Keeping the radial clearance similar to the Maverick, the ball and socket dimensions varied between 10 to 16 mm and 10.015 to 16.015 mm, respectively, in order to enable the comparison between different dimensions. The implants were made out of Cobalt Chrome Molybdenum alloy, with a surface roughness of 0.05 μm.

A Bose spine simulator (Bose Corporation, ElectroForce Systems Group, Minnesota, USA) was used to apply an axial compressive force to the TDA. Axial rotation of ±2° was then applied at various frequencies and the resulting frictional torque measured. The tests were performed under an axial load of 50, 600 and 1200 N and frequencies of 0.5, 1.0, 1.5 and 2.0 Hz, for four different samples of radii 10, 12, 14 and 16 mm (48 combinations in total).

The results showed variation of frictional torque in different frequencies for all four samples under constant axial load. It was observed that the frictional torque had the lowest value for the implant with ball radius of 16mm. It might be concluded that the implant with larger ball radius may create less friction and hence offer a longer life.

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.

Spinal Deformity Service, Royal Orthopaedic Hospital, Birmingham, UK

To describe the technique of nonfusion annulotomy and nuclectomy with posterior growing rod instrumentation for the treatment of non-congenital early onset scoliosis

To present our results of the application of this technique in a consecutive series of nine patients with mean follow up of 76 months (range 16 to 123 months)

We undertook retrospective observational casenote and radiograph study of patients with noncongenital early onset scoliosis having annulotomy and nuclectomy at the apex of their respective curves with standard posterior growing rod instrumentation between 1998 and 2009.

10 patients were identified with one excluded due to short follow up period. Of the nine patients included mean follow up was 76 months. Mean age at primary surgery was 71.7 months (range 29- 97 months)

We measured pre and post operative Cobb angle, T1-S1 height change and change in height over the apical segments.

Mean pre op cobb angle was 74° (range 62- 81°). Mean post op cobb angle was 38°. Three patients have completed their treatment programme with a mean number of 9 lengthenings achieved. Six patients are still undergoing lengthenings. CT demonstrates that the annulotmized segment does not fuse at a mean 3.5 years postoperatively. All patients demonstrated growth over total spinal height and also over apical segments which had undergone annultomy/ nuclectomy. We also report complications.

We have demonstrated that anterior annulotomy and nuclectomy with posterior growing rod construct does allow for spinal growth over released segments without autofusion.

Peninsula Spinal Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK.

A retrospective audit in 2000 of cases presenting with metastatic cord compression (MSCC) was conducted. In June 2009 we introduced the role of MSCC coordinator. We present the preliminary results from a 6 month comparative audit and discuss whether implementation of the NICE Guidelines have improved the care pathway.

Prospective cohort study with retrospective controlled group.

Adults with suspected MSCC

Length of time to MR imaging

% referred for surgical opinion

Length of time on bed rest.

% undergoing surgery

Retrospective audit 2000

38 cases confirmed MSCC.

11 did not have MRI and were treated on the basis of clinical symptoms.

Average time from admission to MRI 42 hours.

8 patients (21%) referred for surgical opinion.

None had surgery

38 had radiotherapy.

Spinal stability documented on 1 patient.

5.5 days average bed rest

Prospective audit 2009

54 patients referred to co-ordinator as suspected MSCC.

52 had MRI and 2 had CT.

Average time from referral to MRI 41 hours.

Average time for patients with neurological deficit 7.6 hours.

54 patients (100%) referred for surgical opinion.

12 patients had surgery (22%).

100% patients had spinal stability documented.

Average length of time on bed rest 2 days.

It is uncertain whether these results are attributed to the introduction of the NICE guidelines or improved awareness of condition. However we feel that NICE guidelines have improved the care pathway of patients with MSCC.

Statement of ethics and interests: Study was approved and registered with audit department.

Modern techniques facilitate the treatment of adult spinal deformity. Decision making is a challenge because of potential complications relating to the surgery itself and medical problems. This study aims to provide useful data in facilitating the decision making process.

Retrospective analysis of consecutive single surgeon series of patients aged >50 between 2006-2009 undergoing multi-level spinal deformity surgery with concomitant decompression. Medical co-morbidities, age and ASA were recorded.

71 patients (57 female) mean age 66 (50-83). 29 (12 multiple) failed previous stenosis surgery. 14(19.7%) in hospital complications in 11(15.5%) patients. 4 were ‘medical’. 8/11 patients were revision cases versus 3/11 primary. 4 patients (5.6%) needed further surgery. 13(18.3%) outpatient complications in 12(16.9%)patients. 7/12 occurred in revision cases versus 5/12 in primary. 11(15.5%) needed further surgery.

Revisional surgery in adult deformity presents a significantly higher overall complication rate than primary surgery (p= 0.0084), but both revisional and primary cases have a relatively high re-operation rate once initially discharged. The results indicate that complex medical and surgical factors contribute to the decision making challenge in patients with adult spinal deformity and stenosis.

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis.

Thirty two Levels in Twenty Six patients were followed up with standardised radiographs after insertion of Wallis Ligaments for Foraminal Stenosis. Wallis ligaments as a top-off or those with prolapsed discs were not included. The Radiological parameters compared were Anterior and Posterior Disc height, Foraminal height and width, The inter-vertebral angle (IVA), Lumbar lordosis and Scoliosis if any. The presence of slips and their progression post-op was noted, as was bony lysis if any.

There were ten males with thirteen levels and sixteen females with nineteen levels in the study. Eighteen levels (56.25%) were L4/L5, ten (31.25%) were L5/S1 and 4 (12.5%)were L3/L4. The average age in the series was 59.6 years (Range 37 – 89 yrs). Average follow up was 9.5 months (Range 2 to 36). The Average increase in Anterior disc height was 1.89 mm (+/−1.39), the posterior disc height increased by an average 1.09 mm (+/−1.14). Foraminal height increased by an average 3.85 mm (+/− 2.72), while foraminal width increased by 2.14 mm (+/− 1.38). The IVA increased in 16 and reduced in 15 patients, with no change in 1. Lumbar Lordosis increased in 23 patients, with an average value of 2.3°. No patient exhibited progression in scoliosis and no lysis could be identified. There were three Grade I slips pre-op; none progressed.

Foraminal dimensions and Disc height were consistently improved after Wallis insertion. Changes in IVA and Lumbar lordosis were however variable. A longer follow up is suggested to look for sustained improvement and the presence of lysis.

MRI scanning of spinal patients at the Primary Care Triage stage is pivotal in reducing inappropriate referrals into Secondary Care.

A retrospective study was undertaken. Details of patients from spinal triage clinics referred for MRI scan were collated together with a provisional diagnosis. Following imaging the results and management plan were documented.

2191 Patients referred via GP's to Physiotherapy Specialist- lead spinal triage clinics from April to September 2009 inclusive.

Referred to a spinal consultant routine/urgent, Managed conservatively, Failed to attend for MRI scanning or MRI cancelled, Sent for scanning for reassurance and discharged.

Of 2191 patients seen in a 6-month period 194 (9%) were referred for MRI of which 81 (41%) were referred on to spinal consultant. This equates to 3.7% of the total number of patients triaged.

Specialist physiotherapy diagnosticians with access to MRI scanning, allows simultaneous treatment and seamless transfer to spinal consultants for surgical intervention if appropriate¹. This process is used effectively to manage large numbers of spinal referrals and minimises the number of patients seen unnecessarily in secondary care¹. This is only possible with close multidisciplinary team working².

Tapping the radial side of the wrist normally elicits a reflex contraction producing elbow flexion, wrist extension and wrist radial deviation. An abnormal response, consisting of finger flexion when performing this manoeuvre is known as the inverted radial (supinator) reflex (IRR). The significance of this reflex in asymptomatic subjects is unknown.

To document the frequency of the IRR in an asymptomatic population and to identify any presymptomatic pathology in those subjects.

The study group consisted of patients and staff at the senior author's institution. Patients were taken from clinics where the complaints were of lower limb symptoms. Subjects were excluded if they had any history of neck pain or stiffness or if they had any subjectively abnormal sensation. The radial reflex was elicited with a tendon hammer. Those subjects with an IRR were asked to attend for a MRI scan of the cervical spine to investigate for any abnormality.

47 subjects were studied. There were 8 subjects who displayed an IRR. In 4 subjects the IRR was unilateral and in 4 bilateral. Seven subjects consented to further investigation by MRI. The average age of these patients was 36 years.

The MRI scans revealed normal appearances in 6 cases. There was no cord signal abnormality in any case.

The IRR occurred with a frequency of 17% in the study group. There was no significant cervical pathology identified in these subjects.

In young asymptomatic patients, the presence of an inverted radial reflex is of no diagnostic relevance.

Post traumatic stress disorder (PTSD) is well recognised in children having repeated medical/surgical procedures. It has been suggested that it is common in young children undergoing growing rod treatment with ongoing lengthening and the inevitable accompanying complications.

We present an index case history, review the literature in order to infer a correlation for the incidence of PTSD and discuss diagnosis and management.

We present an index case history of PTSD in a young child undergoing growing rod treatment for scoliosis. The literature was reviewed for PTSD in paediatric surgery and pathologies requiring multiple treatments. Spinal surgery is compared with paediatric cancer, burns, organ failure/transplant, cardiopulmonary disease, inflammatory bowel disease, cystic fibrosis and limb lengthening.

No published studies examine PTSD in children undergoing multiple spinal surgeries. One paper reports that children undergoing growing rod treatments show “behavioural alterations” and changes in psychosocial behaviour, including anxiety on entering the operating room and broken rod worries. A recent spine meeting presentation referred to this.

Psychosocial problems occur in up to 30% of children with chronic or life-threatening illnesses which involve ongoing treatments. Factors such as age, parental anxiety and previous adverse medical experiences influence anxiety, depression and PTSD.

Based on our index case and methodological correlation with similar pathologies, we fell that PTSD is a genuine concern in children who have repeated spinal operations.

This paper is part of an ongoing study, but we believe that the spinal community should be aware of this diagnosis and its management.

Ethics approval: Audit Interest Statement: None

AO Spine Reference Centre & Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Australia

Traumatic spinal cord injury (SCI) is a devastating condition with no curative therapy. Pro-inflammatory therapy has been suggested recently to try and reduce the inhibitory glial scar and promote neural regeneration and healing. The aim of this study is to investigate the potential of sustained delivery of angiogenic/pro-inflammatory growth factors to reduce the secondary degeneration after spinal cord injury.

Adult male Wistar Kyoto rats (200-300g; 12-16weeks old) were subjected to cord hemisections via a T10 laminectomy. Animals were randomised to treatment or control groups after the spinal cord injury had been induced. Treatment consisted of implantation of a mini-osmotic pump capable of delivering 5 micrograms vascular endothelial growth factor (VEGF) and 5 micrograms platelet-derived growth factor (PDGF), via a catheter, to the site of the lesion, over 7 days(n=6). Control animals were subjected to either cord lesion only (n=6) or lesion plus mini-pump delivering PBS (phosphate-buffered saline) solution (n=6). Rats were sacrificed at one month and the spinal cords were harvested and examined by immunohistology, using anti-neurofilament-200 and anti-Glial Acidic Fibrillary Acidic Protein (GFAP) antibodies.

RESULTS: Active treatment spinal cords showed a higher level with aboration of the axonal filament through the defect and more dense neurofilament-200 staining at the lesion site compared to both control groups. The treatment also showed the elevated presence of activated microglia in the lesion, whilst distal to the lesion the microglia and astrocytes retained an unreactive phenotype.

Pro-inflammatory therapy in the rat spinal cord-injury model showed favourable histological findings after sustained delivery of PDGF and VEGF

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated.

To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯.

Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment.

All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above.

In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up.

Clinical and radiological outcomes were compared at 6 months and 1 year.

Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05).

Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively.

To determine if the term “back pain” has uniform meaning to spinal surgeons.

A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain.

An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting.

67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05).

The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral.

This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

To audit the routine measurement of Vitamin B12 levels prior to cervical decompressive surgery

Retrospective analysis of medical records and pathology results of patients who underwent decompressive cervical surgery for myelopathy over a 6 month period

26 patients were identified from theatre records.

21 out of 26 patients did not have vitamin B12 levels checked prior to their decompressive surgery

The reports in the literature of co-existent B12 deficient myelopathy and mechanical compression are a cause for concern. Although the incidence of this is unknown and unlikely to be common, good clinical practice would suggest that we should be routinely monitoring B12 levels in myelopathic patients.

We have introduced new standards for routinely checking B12 levels pre-operatively and intend to re-audit the effectiveness of these in six months time.

To establish the current practice of spinal cord monitoring in units carrying out scoliosis surgery in the UK.

To illustrate the benefit of routinely monitoring motor evoked potentials (MEPs).

Questionaire: Nationwide survey of spinal monitoring modalities used by spinal units carrying out deformity surgery.

10 out of 27 units routinely measure motor evoked potentials (MEPs), the remainder use only sensory potentials (SEPs). There is significant variability in use of monitoring around the UK and we have compared this to the practice elsewhere in the world.

We report the case of a thirteen year old girl who underwent posterior instrumentation for correction of an idiopathic scoliosis. Intra-operatively there was a significant reduction in the amplitude of the MEPs without any corresponding change in the SEPs. These changes reversed when the correction was released. The surgery was abandoned and was carried out as a staged procedure, initially anteriorly then posteriorly. There was no loss of motor potentials during either operation and no post operative neurological abnormalities.

We propose that the changes noted initially were due to transient ischaemia of the cord which would not have been detected without MEPs and may have led to long term sequelae. This highlights the safety benefit of routinely using MEPs in scoliosis surgery.

Nationally there is wide variation in the monitoring of spinal cord function during scoliosis surgery. We feel that monitoring of motor potentials is a vital component in ensuring scoliosis surgery is as safe as possible.

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”.

Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans.

Patients with suspected spinal stenosis undergoing MRI.

Incidence of “foraminal stenosis” on radiologists' reports.

Diagnoses obtained by different scanning methods.

Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences.

Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression.

In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis.

Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging.

Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation.

A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use.

A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications.

Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate.

The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes.

This study did not require ethics approval and no financial support was received.

The Walter Reed Visual Assessment Scale (WRVAS) is a valid and reliable tool, designed to measure physical deformity as perceived by patients with idiopathic scoliosis. It is unclear whether the type of treatment in patients with thoracic adolescent idiopathic scoliosis affects the patients' perception of cosmesis gain. We studied 40 patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with (20) and without thoracoplasty (20) aiming to assess correlation of improvement in radiological parameters to subjective cosmesis gain.

Patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with thoracoplasty (20) and without thoracoplasty (20) filled out Walter Reed Visual Assessment Scale (WRVAS) forms with their perception of deformity before and after operation at the clinic follow-up. The WRVAS forms include seven aspects of the deformity i.e. spinal deformity, rib prominence, lumbar prominence, thoracic deformity, trunk imbalance, shoulder asymmetry and scapular asymmetry. Each aspect is shown with five figures of increasing severity of the deformity and scored from minimum (1) to maximum (5). Results are presented as the sum of the seven questions. The lowest possible score for the total is 7, while the highest possible total score is 35. The curve magnitude was divided into 5 subgroups as 30 and under, 30-40, 40-50, 50-60 and 70 and over.

Floor and ceiling effects were analysed as percentage of cases with minimum and maximum scores.

Our study confirmed that following posterior scoliosis surgery with and without thoracoplasty, there was significant improvement in perceived appearance. Overall spinal deformity and thoracic deformity correction were comparable in two groups. However, improvement in rib hump prominence, flank prominence, restoration of truncal, shoulder and scapular symmetry were much better rated by the patients with PSF and thoracoplasty group using Walter Reed Visual Assessment Scale.

Following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000 and recommendation from International Commission on Radiological Protection (ICRP), the establishment of diagnostic reference levels (DRLs) for all radiological examinations became mandatory. There are no recommended or published standards or national dosage guidelines in the UK of diagnostic reference levels available for fluoroscopy-guided diagnostic and therapeutic spinal procedures. The aim of this study is to establish reference dose area product (DAP) levels for the diagnostic spinal procedures requiring fluoroscopy as a basis for setting DRLs.

All patient data consisted of diagnostic spinal procedures done in 2009 at Newcastle General Hospital under care of 4 spinal surgeons. Radiation data were collected on specific type of the procedure, DAP and screening time. Nerve root blocks, facet joint blocks and facet joint rhizolysis were included for data collection and analysis for this study. The third-quartile values were used to establish the DRLs.

There were 387 nerve root blocks with a mean exposure per injection 171.3 cGycm² (range, 3.0 to 2029.1; third quartile 209.4). Facet joint injections were 669 at a mean radiation dose 41.3 cGycm² (range, 1.9 to 541.0; third quartile 48.9). In a total 430 facet joint rhizolysis, the mean exposure was 44.4 cGycm² (range, 7.7 to 154.5; third quartile 58.4). The mean screening times were 36.7s (range, 0.4-281s; third quartile 41s) for nerve root blocks, mean 11.2s (range, 1.8-37s, third quartile 13.3s) for single facet joint block and mean 14.6s (range, 0.1-162s, third quartile 15.1s) for single facet rhizolysis.

We found the third-quartile values for setting DRLs for single level nerve root block, single facet joint block and single facet joint rhizolysis to be 209.4, 48.9 and 58.4 cGycm² respectively. We recommend that all spinal units in the UK should establish their own local DRLs to help in establishing national dosage guidelines for fluoroscopy-guided diagnostic and also therapeutic spinal procedures.

To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular Vertebroplasty in cadaveric vertebra

Cadaveric single level vertebra were used to evaluate Bipedicular versus Unipedicular Vertebroplasty as an intervention for vertebral compression fractures

Cadaveric vertebra were assigned to two arms: Arm A simulated a wedge fracture followed by bipedicular cement augmentation; Arm B simulated a wedge fracture followed by unipedicular cement augmentation. Micro-CT imaging was performed to assess vertebral dimension, cement fill volumes and bone mineral density. All augmented specimens were then compressed under a static eccentric flexion load to failure.

Pre and post augmentation failure load and stiffness were used to compare the two groups.

Results suggest, when compared with actual failure strength, that the product of bone mineral density and endplate surface area gave a good prediction of failure strength for specimens in both arms. The mean cement volume fill of augmented vertebral bodies was 22.8% ± 7.21%. The bipedicular group showed a reduction in stiffness but an increase in post augmentation failure load of 1.09. The unipedicular group also showed a reduction in stiffness but showed a much greater increase in post augmentation failure load of 1.68.

Preliminary data from this study suggests there is a significant reduction in stiffness following both bipedicular and unipedicular vertebroplasty. There is a significant increase in failure load post augmentation in the unipedicular group.

Back pain is extremely common in soldiers undergoing training¹. There is no data worldwide with regards to incidence, prevalence and impact of back pain in a deployed military population. This study was undertaken to evaluate these issues.

1000 back pain questionnaire were distributed over a period of four days at the main military base in Basrah in February 2009 in different locations. The filling out was anonymous and completely voluntary.

UK military personnel

Information was obtained about age, BMI, length of service, rank, incidence, prevalence, onset, admission rate, treatment, aero-medical evacuation, operational effectiveness, pain killers and VAS.

768 (77%, 26% of population at risk) questionnaires were returned Prevalence of back pain was 33.4% (257). A greater prevalence occurred in the combat arms (41.7%, p=0.01) and those of over 12 years service (44%, p=0.004). No statistical difference was found with rank, or BMI. 74 people (9.6%) had developed new onset back pain since deploying. Recurrent pain occurred in 38.9% of the whole sample. VAS showed a normal distribution. 35% of those affected were discharging their duty with mild difficulty but around 6% were having great difficulty. 25% were on regular analgesics. Back pain constituted 23% (137/583) of the physiotherapy dept caseload, 6.6%, (25/378) of ward admissions and 0.04% (5/119) of aero-med patients.

Back pain is a major problem among deployed personnel. However with adequate resources the vast majority can be managed in the field thus reducing attrition rates² and maintaining operational effectiveness. Further studies should be undertaken to assess if back pain persists after deployment.

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 audit patient satisfaction throughout the perioperative period amongst emergency and elective admissions in the spinal team.

92 patients were identified whom underwent operations within a 3 month period using the operating database. A self administered postal questionnaire was sent to assess preoperative waiting time, quality of preoperative assessment and information given, assessment of their admission, their experience throughout hospital stay and the quality of their post operative assessment and discharge.

Patient reported outcomes (PROMS)

Response rate 35% (32/92) of which 24 (14F 10M) were elective admissions and 8 emergency admissions (2F 6M). Average wait for elective procedure was 5.7 weeks (median 2).

63% of elective patients were seen in prescreening clinic and 79% of these received an information booklet prior to operation.

22% of patients had delayed discharge due to non clinical causes including awaiting transport, awaiting medications and physiotherapy clearance.

88% of patients reported they were given adequate information regarding post-operative daily activities.

79% of elective patients reported seeing a doctor on the day of their discharge however only 38% reported seeing a physiotherapist postoperatively. This fell to 0% for patients operated on a Friday.

Although 94% of patients reported that they were satisfied with the overall care they were given, they reported certain aspects of their clinical care being less than optimal.

Trust wide assessment of patient reported outcomes to assess and improve the quality of care against national guidelines.

Ethics Approval: Self questionnaire approved by ethics committee

Royal Liverpool University Hospital, Liverpool, UK

To retrospectively review outcomes in patients who underwent vertebroplasty in Liverpool in response to recent level 1 publications claiming vertebroplasty to be no better than sham procedure assessed using 2 criteria. We reviewed cases between 2006 and 2009 looking at 5 criteria for procedure.

Visual Analogue Score (VAS)

Oswestry disability index scores (ODI)

96 patients identified. 10 patients excluded (inadequate data recorded) (n=86). Operated levels n=134 (thoracic n=61, lumbar n=71, sacral n=2).

Presenting symptoms included back pain (86/86) and point tenderness was present in 90% (77/86). Average length of symptoms was 11.50 months with 28% reporting greater than 12 months. 72% recalled definite onset of symptoms with 90% being associated with a low velocity injury. Radiological findings showed an average of 54% height collapse and 91% showing high signal on STIR MRI sequences. Number of levels operated – 3 or more (n=9 VAS 5.3 ODI 10.6); 1 to 2 levels (n= 77 VAS 3.7 ODI 13.9)

Average improvement in VAS score was 3.8.and ODI 13.6

47% (40/86) of patients met all 5 current criteria recommended for operation (VAS 3.7, ODI 14). 53% (46/86) of patients met 2-5 criteria (VAS 3.8, ODI 13.4).

There was improvement in pain scores in 91% of patients with an average pre-op VAS 7.8 and post-op VAS 4.0. There was no significant difference in patients meeting all 5 criteria compared to those meeting 2-5 criteria.

Proponents of thoracoplasty suggest a better correction, obviating iliac crest donor site morbidity, obtaining bone grafts for fusion and better rib hump correction. Opponents suggest increase risk for chest complications, additional operating time and blood loss, and possible longer hospital stay. There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

It is a retrospective study of consecutive series of 62 patients with thoracic adolescent idiopathic scoliosis surgically treated by single surgeon between 2007 and 2008 at a tertiary referral Orthopaedic Spinal unit. Posterior spinal fusion and thoracoplasty (n=32, all but one girls) were compared with 30 without thoracoplasty (all but one girls). Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 3-months, 1 year and/or 2-year follow-up, and comparisons were made between two groups. The minimum follow-up was one year.

No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up ranging 1 to 3 years. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients compared to patients treated by posterior spinal fusion alone. Three-month postoperative pulmonary function test values in both groups experienced 15-30% decline which returned to the preoperative baseline at 1 year in > 90% patients. In thoracoplasty group, 5 to 8 ribs were resected and used for bone graft. Chest complications were observed in 2 patients requiring chest drainage. Prolonged donor site morbidity was noted in 3 patients.

Thoracoplasty showed comparable clinical and radiological correction without any significant pulmonary function compromise. Pulmonary function test values returned to the preoperative baseline at 1 year in > 90% patients.

Patients with peripheral primary bone tumours are often identified and referred at an early stage to a regional tumour service according to established guidelines. In patients with primary bone tumours of the spine, however, the definitive management or outcome of such patients is being prejudiced by preliminary intervention from non-specialist services prior to their referral.

Objective: To audit the standards of management of patients with primary bone tumours of the spine referred to a regional tumour service.

Retrospective review of case notes and radiology.

Subjects: Patients with primary bone tumour of the spine managed at the Orthopaedic Spine Unit with the Regional Bone Tumour Service in Newcastle Upon Tyne Hospitals NHS Trust.

Referral to tumour service, prior intervention, operative treatment, survival, factors affecting definitive management

31 of 39 (16 benign, 23 malignant) patients were initially referred from primary care to services other than the regional tumour service, most commonly neurosurgery (11/39) and paediatric oncology (4/39). Seven of 39 of these patients had undergone interventions prior to their referral to the tumour service, which may have negatively impacted their definitive management or curative surgery.

These tumours present complex issues regarding their definitive management to optimise outcome. Closer links between departments are required to enable the multidisciplinary management of primary bone tumours of the spine. Prior surgical intervention may compromise cure. Those involved in their management should be encouraged to liaise with their regional bone tumour service to improve outcome.

Osteoporotic vertebral deformities are conventionally attributed to fracture, although deformity is often insidious, and bone is known to “creep” under constant load. We hypothesise that deformity can arise from creep that is accelerated by minor injury.

Thirty-nine thoracolumbar “motion segments” were tested from cadavers aged 42-92 yrs. Vertebral body BMD was measured using DXA. A 1.0 kN compressive force was applied for 30 mins, while the height of each vertebral body was measured using a MacReflex optical tracking system. After 30 mins recovery, one vertebral body from each specimen was subjected to controlled micro-damage (<5mm height loss) by compressive overload, and the creep test was repeated. Load-sharing between the vertebral body and neural arch was evaluated from stress measurements made by pulling a pressure transducer through the intervertebral disc.

Creep was inversely proportional to BMD below a threshold BMD of 0.5 g/cm² (R²=0.30, P<0.01) and did not recover substantially after unloading. Creep was greater in the anterior cortex compared to the posterior (p=0.01) so that anterior wedge deformity occurred. Vertebral micro-damage usually affected a single endplate, causing creep of that vertebra to increase in proportion to the severity of damage. Anterior wedging of vertebral bodies during creep increased by 0.10^o (STD 0.20^o) for intact vertebrae, and by 0.68^o (STD 1.34^o) for damaged vertebrae.

Creep is substantial in elderly vertebrae with low BMD, and is accelerated by micro-damage. Preferential loss of trabeculae from the anterior vertebral body could explain greater anterior creep and vertebral wedging.

To investigate whether restoration of mechanical function and spinal load-sharing following vertebroplasty depends upon cement distribution.

Fifteen pairs of cadaver motion segments (51-91 yr) were loaded to induce fracture. One from each pair underwent vertebroplasty with PMMA, the other with a resin (Cortoss). Various mechanical parameters were measured before and after vertebroplasty. Micro-CT was used to determine volumetric cement fill, and plane radiographs (sagittal, frontal, and axial) to determine areal fill, for the whole vertebral body and for several specific regions. Correlations between volumetric fill and areal fill for the whole vertebral body, and between regional volumetric fill and changes in mechanical parameters following vertebroplasty, were assessed using linear regression.

For Cortoss, areal and volumetric fills were significantly correlated (R=0.58-0.84) but cement distribution had no significant effect on any mechanical parameters following vertebroplasty. For PMMA, areal fills showed no correlation with volumetric fill, suggesting a non-uniform distribution of cement that influenced mechanical outcome. Increased filling of the vertebral body adjacent to the disc was associated with increased intradiscal pressure (R=0.56, p<0.05) in flexed posture, and reduced neural arch load bearing (F_N) in extended posture (R=0.76, p<0.01). Increased filling of the anterior vertebral body was associated with increased bending stiffness (R=0.55, p<0.05).

Cortoss tends to spread evenly within the vertebral body, and its distribution has little influence on the mechanical outcome of vertebroplasty. PMMA spreads less evenly, and its mechanical benefits are increased when cement is concentrated in the anterior vertebral body and adjacent to the intervertebral disc.

Healthcare interventions are under increasing scrutiny regarding cost-effectiveness and outcome measures have revolutionised clinical research.

To identify all available outcome questionnaires designed for lowback, lumbar spine pathologies and to perform qualitative analysis of these questionnaires for their clinimetric properties.

A comprehensive e-search on PUBMED & EMBASE for all available outcome measures and published review articles for lowback and lumbar spine pathologies was undertaken over a two month period (Nov-Dec 2009). Twenty-eight questionnaires were identified in total. These outcomes questionnaires were evaluated for clinimetric properties viz:-

Validity (content, construct & criterion validity)

Reliability (internal consistency & reproducibility)

Responsiveness and scored on a scale of 0-6 points.

Eight outcomes questionnaires had satisfied all clinimetric domains in methodological evaluation (score 6/6).

Oswestry disability index (ODI)

Roland-Morris disability questionnaire (RMDQ)

Aberdeen lowback pain scale

Extended Aberdeen spine pain scale

Functional rating index

Core lowback pain outcome measure

Backpain functional scale

Maine-Seattle back questionnaire.

Sixteen of these questionnaires scored =5 when evaluated for clinimetric domains. RMDQ had the highest number of published and validated translations followed by ODI. Criterion validity was not tested for NASS-AAOS lumbar spine questionnaire.

32%(9/28) of the outcome instruments have undergone methodological evaluation for =3 clinimetric properties. Clinicians should be cautious when choosing appropriate validated outcome measures when evaluating therapeutic/surgical intervention. We suggest use of few validated outcome measures with high clinimetric scores (=5/6) to be made mandatory when reporting clinical results.

The study was designed to observe the patients emotional and physical response to total disc replacement surgery in the cervical spine.

A prospective cohort study of patients undergoing Cervical total disc replacement (TDR) surgery at our institution. Surgery was carried for radicular and or axial neck pain. The Activ-C TDR (Aesculap) was used. Pre and post operative data was collected using validated questionnaires.

13 Consecutive patients from Nov 2007 to Aug 2008 were studied. All patients were planned for surgical intervention for symptomatic degenerative cervical disc disease at single or multiple levels. 7 male, 6 female.

The Centre for Epidemiological Studies Depression Scale (CES-D) was used to assess the psychological impact. The Neck Disability Index (NDI) and a visual analogue scale (VAS) were used to assess the physical impact of the surgery.

NDI shows a significant improvement at 6 and 12 months (p= 0.002 and p=0.02 respectively). The VAS also shows significant improvement at 6 and 12 months (p=0.004 and 0.008 respectively) The CES-D improved but failed to show any significant improvement at either interval.

In our patient population surgical intervention with TDR for degenerative disc disease offers significant physical benefit over the short term. This does not correlate with an improvement in their emotional state.

Anterior only procedure for stable thoraco-lumbar burst fractures is controversial.

Prospective collection of clinical and radiological data in stable burst fractures with neurological deficit undergoing anterior only decompression and stabilisation with 2-year follow-up.

14 consecutive patients (8 females, 6 males) with two-column thoracolumbar burst fracture and neurological deficit underwent anterior corpectomy/hemi-corpectomy and instrumentation, from February 2007 to February 2009.

Radiological data included classification of fracture (AO classification), kyphus angle and degree of canal compromise. Post-operative CT scans done to assess radiological improvement.

Clinical data included neurological deficit at presentation, improvement or changes in neurology, length of surgery, estimated blood loss, post-operative complications and length of stay.

Commonest mechanism was fall from height. 10 patients had incomplete burst fractures amenable to hemi-corpectomy. 8 of our patients were ASIA D, 4 were ASIA C or lower. They all improved by at least one grade. 2 patients had identical ASIA grade pre and post operatively. Pre-operative spinal canal compromise averaged 52.6% and vertebral body height loss averaged 48.9%. The mean kyphotic angles improved from 19.6° to 7.9 °. There were two cases with minor injury to the diaphragm, one developing a pneumothorax. Mean length of surgery and hospital stay were 4hours and 21minutes and 11.8 days respectively.

The fractures in which the top part is burst and causing canal compromise, could be dealt with by top hemi-corpectomy requiring smaller approach. One stage anterior – only stabilization can yield successful clinical results.

Assessment of long term results of Chemonucleolysis vs. surgical enucleation in soft disc herniation

From 1982 to 1985, 100 patients with symptomatic disc herniation were randomly allocated to receive either Chemonucleolysis or disc enucleation after all these patients had a trial of conservative treatment for three months.

The outcome of result was measured using MacNab Criteria with the help of

Questionnaire

Assessing the patients in clinic

44 patients out of original 100 patients were followed up in the clinic 25 years later. 24 were from chemonucleolysis group and 20 from the surgical group.

According to MacNab criteria 62.5% had excellent or good results and 25% poor results in chemonucleolysis group and in surgery group 70% had excellent or good results and 10% poor results. Patients with poor result in Chemonucleolysis group consisted of: a) 1 had poor result post TKR, b) 4 were offered surgical enucleation subsequent to failed Chemonucleolysis though they did not seem to benefit from surgery and 1 out of these 4 also had fibromyalgia. c) 1 had poor result after sustaining fracture neck of femur. Poor results in surgical group were due to persistent back pain.

The results at 25 year follow-up have shown no statistically significant difference between the patients treated by either chemonucleolysis or surgery. The added benefit of using the chymopapain injection is that it is of lower cost. Chemonucleolysis should have a wider role in treatment of intervertebral disc herniation.

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique.

We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared.

Tumours were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group.

The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery.

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy.

Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD).

A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant.

Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes.

Review the complications reporting in 4 prominent spinal journals over the last decade.

Computerised search of the Medline database and hand search was undertaken to evaluate the complication reporting in 4 spinal journals (Spine, European Spine Journal, Journal of Neurosurgery Spine and Journal of Bone and joint surgery) from 2000 to 2009. The articles were divided based on the level of NICE evidence classification A to D.

A total of 88 articles reported spinal complications. Of these 5.9% was level B, 8.8% was level C and 85.3% was level D. There were no RCT's reported relating to complications (Level A) and majority of complications were case reports or expert opinions (level D). For the proportion of level D the rank order of the journals was; Spine (4.8%), European spine journal (3.8%), Journal of neurosurgery spine (5.1%) and Journal of bone and joint surgery was (1.8%). There was no increase in the rate of reporting over the decade. A detailed discussion of the reporting will be presented.

Papers focusing primarily on complications and its management are still not the focus in most surgical journals. This review over the last 10 years confirms that only rare and uncommon complications are reported in the form of case reports. Meta analysis or case series of complication is rarely reported. More focus must be emphasised on reporting mortality and morbidity for education.

The aim of this study was to prospectively assess the outcome of patients with metastatic spinal disease who underwent minimally invasive fixation of the spine for intractable pain or spinal instability.

This is a prospective audit of patients with metastatic spinal cord disease who have undergone minimally invasive fixation of the spine from August 2009 until the present date. This was assessed by pre and post-operative Oswestry Disability Index (ODI), EQ5D and Tokuhashi scores. Intra- and post-operative complications, time to theatre, length of inpatient stay, analgesia requirements, mobility, chest drain requirement and post-operative HDU and ITU stays were also recorded.

So far, 10 patients have met the criteria. There were no intra-operative complications. Post-operatively, there were no complications, chest drains, increase in analgesia or stay on the HDU or ITU. All patients showed an improvement in mobility. The mean post-operative day of mobilisation was 2 days, post-operative days until discharge 5.3 days and length of inpatient stay was shorter than traditional surgery. Blood loss was minimum except one patient with metastatic renal cell carcinoma who needed transfusion intraoperatively.

ODI, VAS and EQ-5D scores were calculated and were significantly improved compared to preoperatively.

This novel approach to management of metastatic spinal disease has resulted in improved mobility, short inpatient stays without the need for chest drains, HDU or ITU and an improved the quality of life in pallliative patients. This is a completely new strategy to treat the pain in these patients without the usual associated risks of surgery and has major advantages over traditional surgical techniques which may preclude this group of patients having any surgical stabilisation procedure at all

Following studies in 2007-08 comparing cervical discs devices, satisfaction and accuracy of operated and adjacent levels was observed with titanium devices. Patients were followed up and surgical assessments recorded.

MRI with 12 patients were first assessed for imaging quality. Two independent radiologists scored twice sagittal and axial T2 – weighted images using the Jarvik four point scale. Statistical analysis was performed on operated and adjacent levels and between devices. Length of surgery, blood loss, approach and time of exposure to radiation were recorded. Patients were followed up at two years.

BAGUERA C containing titanium metal allowed satisfactory visualization of the canal, exit foramina, cord and adjacent levels. PCM and PRODISC C visualization was significantly impaired at operated level and in both spinal cord and neural foramina. At adjacent levels, image quality was statistically poorer for those two devices. 6 patients were operated at C5-C6 and 6 at C6-C7. Mean age was 49. Approach was from the right, length of surgery and blood loss were: mean 46 min and 16.25 cc for BAGUERA C; mean 70 min and 27.5 cc for PCM and mean 63 min with 26.25 cc for PRODISC C. Exposure to radiation presented also significant difference between devices. Clinical outcomes reveal similar VAS and patient's satisfaction scores.

Titanium device with polyethylene allow for satisfactory monitoring with adequacy in the assessment of neural decompression. BAGUERA C surgical outcomes indicate potential benefits that may be related to technique and simplicity of implantation.

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain.

56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met.

56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied.

Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported.

To assess how effective are the prognostic scores and the role of delayed presentation in predicting the outcomes in patients with metastatic spine disease.

Retrospectively data collected from December 2006 to December 2009. Medical records review included types of tumours, duration of symptoms, duration from referral to definitive treatment, expected survival, functional status before and after treatment. Karnofsky performance score and Modified Tokuhashi were used.

Results: 50 patients underwent surgical stabilisation for metastatic spine disease with or with out cord compression. Age ranged from 39 to 87 years (Avg: 64). Patients had four main types of tumours; (Myeloma 30%, Lymphoma 22% Lung CA 16% and Renal 12 %).

Inpatients without cord compression, the average time from referral to definitive treatment is 17 days. Over all fictional status improved in 70% of cases following surgical intervention. Patients who presented with cord compression had surgery with in 49 hours. Patients with high prognostic scores did not survive as long as expected. On the contrary, patients with poor prognostic scores survived longer than expected. This discrepancy is significant in patients with lung and renal malignancies. Patients with Myeloma did well as per the prognostic scores.

Prognostic scores are not uniformly effective in all types of malignancies. Factors like delayed presentation and general condition were not included in the prognostic factors. Hence, we conclude that we cannot make a decision purely based on the prognostic scores to perform either palliative or definitive surgery.

Different methods of lateral mass(LM) screw placement in the cervical spine have been described. In the axial plane, 30 degrees is the recommended angle to avoid neurovascular injury. The estimation of this angle remains arbitrary and operator dependant.

To assess how accurately the lateral trajectory angle (LTA) for cervical LM screws is achieved by visual estimation amongst experienced spinal surgeons.

A sawbone model of cervical spine with simulated lordosis was used. Five spinal consultants and five senior spinal fellows were asked to insert 1.6 mm K wires into lateral masses of C3 to C6 bilaterally to simulate screws. The LTA in transverse plane was measured using a customised protractor. Basic statistical analyses of all the data were obtained. Using all the angles derived, a virtual screw trajectory was drawn in the lateral plane, on a normal axial Computerised Tomography scan of cervical spine of an anonymous patient using PACS system.

The overall mean LTA for the group was 25.15 degrees, that of the fellows 24.4 and consultants 26.2 degrees. Mean deviation from 30 degrees for fellows was 5.2 and 6.4 degrees for consultants. Overall standard deviation was 4.78, for fellows and consultants it was 3.3 and 5.8 respectively. Two episodes of vertebral artery injury occurred at 15 and 16 degrees with simulated angles on CT.

A moderate variability in visual estimation of the trajectory angle exists even amongst experienced surgeons during insertion of cervical LM screws. An anatomical landmark would be useful to improve the reliability of the procedure.

To describe the development of a system of referral, initial data acquisition and subsequent database recording and outcome reporting for metastatic spinal cord compression.

Deficiencies in the literature identified by the NICE GDG for MSCC for research were compared with our original database and modifications made to ensure prospective collection of currently recognised and some proposed relevant factors.

In addition modifications were made to ensure that all NICE implementation audit data and “target “ data are recorded and can be seamlessly transferred to necessary destinations

This generates standardised reports of the presentation, management and longitudinal interval outcomes including analogue pain scales, analgesic requirement, neurological function, Karnofsky performance indices, Euroquols, and ODIs. It includes pretreatment prognostic indices (updated 2005 Tokuhashi scores) relevant to treatment selection and scale of surgical intervention. Outcomes can be subclassified by type of intervention relative to clinical status at intervention

In house live assessment has revealed some reducing minor operational flaws and initial external assessment is current.

A comprehensive information system and treatment guide for this increasing group has been developed and is evolving. Common adoption would facilitate earlier recognition and optimise treatment to diminish the high human and financial cost of MSCC. Currently networks are setting up NSSGs and for this process to be enhanced and to avoid costly duplication adoption of this system modified following peer review is suggested.

The “Wallis” implant is indicated to stabilize symptomatic degenerative lumbar spine segments, relieving low back pain related to instability and thus delaying the need for irreversible, more invasive surgical management. The purpose of this study was to provide the first objective clinical evaluation of the “Wallis” lumbar dynamic stabilisation system.

An independent prospective observational study was carried out utlising SF-36, Oswestry Disability Index (ODI) and visual analogue pain scores (VAS). Surgical pathologies in which this technique was used, the intra-operative and post-operative complications and length of post-op stay were recorded. 102 patients underwent Wallis insertion between June 2007- May 2009, Median age 51.5 (range 28-108). 94% of patients completed questionnaires and were followed up at 3, 6 and 12 month time points. ODI scores decreased from pre-op 39 to 27 at twelve months (p<.0016). VAS back pain scores decreased 59 to 36 (p<0.0001). Leg scores decreased 50 to 39 (p<0.0002). SF 36 scores improved significantly, physical functioning 46 to 59, physical health 30 to 54 and social functioning 47 to 68. 50% of patients believed their health to be better 12 months post-op. Pre-operatively 28% of patients were employed and working with 26% off work due to back problems. This rate increased steadily with 42% employed at 12 months. Two implants were removed, one due to non-benefit with subsequent arthrodesis and one due to infection. One superficial wound infection occurred.

The Wallis dynamic stabilization system provides a superficial and easily reversible surgical procedure with a lower complication rate than conventional athrodesis. Used in patients with painful degenerative lumbar conditions their quality of life objectively approached values of the age- and gender-matched general population.

We do know that the use of stand-alone cage with no plate is prone to subsidence and segmental kyphosis. Cage and plate construct are prone to adjacent level ossification. Zero P (Synthes, UK) cage combines the functionality of spacer and anterior plate.

Radiological evaluation of subsidence of cervical spine after anterior cervical interbody fusion using Zero P cage system.

Method: Retrospective review of radiographic records of patients undergoing surgery between June 2008- Oct 2009. We evaluated lateral cervical standing radiographs before, after, 6 weeks, 3, 6 months of surgery. We measured subsidence (using Total Intervertebral Height (TIH). All measurements were done using Web 1000 (Impax Agfa). Two level was treated as single segment. Subsidence > 3mm was considered significant.

20 patients (11 male: 9 female) with median age of 51 yrs (40-65) underwent one (n=10) or two level (n= 10) cervical fusion. Immediately post-op there was increase in TIH in one and two level group by 1.74mm (1.61 and 4.25mm (1.48 respectively, which at 6 months reduced to 1.05mm (0.24 (p< 0.003) and 1.32mm (1.29 (p< 0.085) at 6 months respectively. Subsidence was seen in all cases and was rapid in first 3 months and then tailed off. It was significant (> 3mm) only in 2/20 (2%) patients at 6 months.

Early results indicate that spine alignment is maintained radiologically with no associated complications as screw loosening, cage extrusion etc.

To compare the ability of fulcrum bend and traction radiographs to predict correction of AIS using screw only implants and to assess the fulcrum bending correction index (FBCI) with a new measurement: the traction correction index (TCI)

Retrospective radiographic analysis of case series (Level IV)

Radiographic correction of scoliosis based on correction rate does not take into consideration the curve flexibility. It has been suggested that fulcrum bending radiographs predict curve correction in AIS [1]. This has been questioned [2] and has been suggested that traction radiographs are more predictive in a mixed group of patients with hybrid and screw only constructs.

Twenty three patients average age 15, who underwent posterior correction of scoliosis using pedicle screw only construct.

Analysis was carried out on the pre-op and immediate post-op AP radiographs and the pre-op fulcrum bend and traction radiographs. Correction rate, fulcrum flexibility, traction flexibility, FBCI and TCI was calculated.

Preoperative mean Cobb angle of 66 degrees was corrected to 25 degrees postoperatively. The mean fulcrum bending Cobb angle was 38 degrees and traction Cobb angle 28 degrees. The mean fulcrum flexibility was 45%, traction flexibility 59% and correction rate 63%. The mean FBCI was 182% and TCI was112%.

When comparing fulcrum bend and traction radiographs, we found the latter to be more predictive of curve correction in AIS using pedicle screw constructs. The TCI better takes into account the curve flexibility than the FBCI.

Clinical and radiological assessment of results of vertebral body stenting procedure.

Introduction: Use of metallic stents along with cement have shown good restoration of the vertebral body in cadaveric spines. We have presented the early results of vertebral body stenting done at Royal Derby Hospitals.

Patients and Methods: All patients had a transpedicular approach to the vertebral body. The vertebral body stent was expanded using a balloon as in balloon kyphoplasty. The balloon was removed leaving the stent in place. The resultant cavity was filled with partially cured polymethyl methacrylate in osteoporotic fractures and calcium phosphate cement in traumatic fractures.

Radiological assessment included pre operative measurement of vertebral body angle, correction achieved and maintenance of correction at follow up

All patients were assessed using the visual analogue score and oswestry disability index.

The procedure was done in 14 fractures (10 patients). 9 fractures were traumatic while 5 were osteoporotic fractures. The mean age of the traumatic fractures was 54.28 years while the mean age of osteoporotic fractures was 82.34 years. Mean follow up was 10 months. All traumatic fractures were type A 3.1. Mean vertebral body angle correction achieved was 8.3° (4° to 14.2°). None of the patients lost the reduction at follow up.

The mean VAS for pain at 6 months was 3.8. The mean oswestry disability index was 22% for traumatic fractures, while it was 44% for osteoporotic fractures.

Vertebral body stenting is a safe procedure. It was successful in restoring the anterior column with encouraging radiological and clinical results.

The purpose of this retrospective study, is to demonstrate the survivorship and clinical effectiveness of the Wallis implant, against low back pain and functional disability in patients with degenerative lumbar spine disease.

The Wallis Interspinous implant, was developed as a minimally invasive and anatomically conserving procedure, without recourse to rigid fusion procedures. The initial finite element analysis and cadaver biomechanical studies showed that the Wallis ligament improves stability in the degenerate lumbar motion segment. Unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels allowing for the potential of the disc to repair itself.

A total of 157 patients who had wallis ligament insertion between 2003 and 2009 were reviewed, with a mean age of 54 and were followed for 48 months on average.

Patients were assessed pre-operatively and post-operatively every 6 months by VAS pain score, Oswestry Disability Index and SF-36.

90% of patients improved, to show a minimal clinical difference, compared to the pre-operative evaluation. There is overall 75-80% good clinical outcome.

Low infection rate of 1.1%. Two cases of prolapsed discs at the same level requiring further discectomy, 7 required fusion. No fractures or expulsions.

The Wallis implant represents a safe non-fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. There is less soft tissue damage, quick rehabilitation, less morbidity and associated low complication rate.

To assess concordance between hospital coding and clinician coding for patients undergoing spinal instrumentation procedures and determine if our coding systems result in accurate financial reimbursement from the primary care trust (PCT).

We conducted a one year retrospective review of 41 patients who underwent spinal instrumentation procedures. Data collected from IT systems included: operation description, clinician procedure code, hospital procedure code, Hospital Health Resource grouping (HRG), clinician HRG, instrumentation costs and PCT reimbursement fees. From this data we compared coding based re-imbursement fees and actual surgical costs, taking into account exact instrumentation prices.

In all cases the primary hospital and clinician coding values differed. Using the clinician code would have altered the HRG group in 16 patients. Using solely clinician coding would have generated less financial reimbursement than using hospital coding.

In 23 patients undergoing complex spinal procedures, instrumentation costs represented a significant proportion of the final fee obtained from the PCT, thus leaving a small proportion for the associated hospital stay costs. This suggests instrumentation costs are inadequately reimbursed from the PCT.

Hospital coding appears more accurate than clinician coding and results in greater financial reimbursement. On the whole, we found there to be insufficient reimbursement from the PCT. The variable and sometimes substantial cost of spinal instrumentation procedures results in inadequate reimbursement for many procedures. We feel the payment by results (PBR) scheme is suboptimal for such procedures and adequate reimbursement can only be achieved by direct billing on an individual case basis.

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst.

A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score.

Overall patient satisfaction was recorded on a scale of 0-10.

38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group.

Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications.

To assess the clinical and radiological outcome of single and multiple level Anterior Cervical Disc Replacement (ACDR) using Peek-on-peek system. We present the largest series of POPCDR at a single centre.

Thirty-one patients with radiculopathy and/or myelopathy caused by disc generation who did not respond to conservative treatments were included. Pain and function were evaluated by VAS (Visual Analogue Score) for neck (VAS-NP) and arm pain (VAS-AP). Neck disability index (NDI) and SF-36 questionnaires were completed. Disc height and segmental angular correction (SAC) were measured on radiographs pre- and postoperatively.

Seven patients had one-level, fifteen had two-level, seven had three-level and two had four-level ACDR. Sixty-six discs were replaced. Average follow-up was six months.

Mean VAS-NP improved from 7.27 to 3.93 and VAS-AP from 7.27 to 3.4. Mean SF-36 improved from 32.21 to 40.22. There was functional improvement for NDI in all patients.

There was an improvement in SAC from 5.4^° to 8.0^° for one-level, 3.1^° to 7.5^° for two level, 8.4^° to 9.4^° for three-level and 5.8^° to 26.7^° for four-level ACDR.

Post-operative anterior disc height increased by 152% for lower and 55% for higher levels. Similar improvements were noted for posterior disc heights.

Early results show that POPCDR is safe and effective for treatment of symptomatic cervical disc disease. The clinical and radiological outcomes are similar to other types of ACDR reported in literature. POPCDR also allows safe use of MRI during follow-up with fewer artifacts giving it an edge over other systems.

Plain radiography has traditionally been used to investigate and monitor patients with adolescent idiopathic scoliosis. The X-ray allows a calculation of the Cobb angle which measures the degree of lateral curvature in the coronal plane. ISIS2 is a surface topography system which has evolved from ISIS, but with much higher precision and speed. It measures the three dimensional shape of the back using structured light and digital photography. This system has the benefit of not requiring any radiation. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane. The aim of this study was to compare this parameter to the Cobb angle measured on plain X-ray.

Twelve patients with idiopathic adolescent scoliosis underwent both a standing AP spine X-ray and an ISIS2 scan on multiple occasions. Both scan and X-ray were done within one month of each other. No patient underwent surgery during the study period. The Cobb angle and the degree of lateral asymmetry were calculated.

Twelve patients mean age 12.5 years (range 10-16) were investigated using both ISIS2 and X-ray. They had a mean 2.3 (1-5) combined investigations allowing for 30 comparisons. The correlation between the two measurements was r =0.63 (p=0.0002). The Cobb angle measured on ISIS2 was less than that measured by radiograph in 27 out of 30 comparisons. The mean difference between the measurements was mean 6.4° with a standard deviation of 8.2° and 95% confidence interval of 3.3° to 9.4°.

In adolescent idiopathic scoliosis, curve severity and rib hump severity are related but measure different aspects of spinal deformity. As expected, these relate closely but not precisely. ISIS2 offers the promise of monitoring scoliosis precisely, without adverse effects from radiation. The small numbers in this series focus on the group of patients with mild to moderate curves at risk of progression. In this group, ISIS2 was able to identify curve stability or progression, without exposing the subjects to radiation.

To review indications, complications and outcome for revision surgery in metastatic spinal disease.

Retrospective review of casenotes and radiographs.

13 patients (9 male, 4 female) identified from a cohort of 222 patients who underwent surgery for spinal tumours between 1994- 2001.

Indication for revision, complications, survival. Further recurrence (same or different level). Further surgery, neurological grade and pain score.

Of 13 patients (4 Renal, 6 breast, 2 prostate, 1 myeloma) one is alive 101 months following revision. Two have been lost to follow up, 10 have died (mean survival 25.3 months post op). The mean time between primary and revision surgery was 10 months (range 1- 32 months)

4 disease progression (same level), 4 new level disease, 3 loss of fixation, 1 radiological collapse, 1 progressive kyphus. Approaches used: 4 anterior, 8 posterior, 1 posterior + anterior. The mean number of levels which required instrumentation on revision was 5.

Modal pain score pre op 5, modal post op 3, minimum one point improvement. Preop modal Frankel grade E, postoperatively all preserved or improved one grade. Modal Karnofsky score preop 70 (30- 90), postop 80 (40-90)- all but one at least 10 point increase. Complications: 1Dural tear, 1 bacteraemia, 1 chylothorax, 1 loss of fixation. 3 patients required further surgery (range 4 months- 18 months, mean 11 months)

Patients with metastatic disease may benefit from second procedures for recurrent disease whether locally or distant with excellent survival, low complications and good function.

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients.

Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009.

Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort.

All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group.

Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future.

The aim of this study is to review the functional outcome of the patients treated with Posterior Lumbar Interbody Fusion for FBSS.

This is a retrospective review of prospectively collected data of 39 patients diagnosed with FBSS and treated with PLIF between June 2000 and December 2008 by the senior author in our unit. Pain and function were evaluated by VAS for Back (VAS-BP) & leg pain (VAS-LP), Oswestry disability index (NDI) and SF-36 questionnaires, and were completed pre- & post-operatively.

There were 39 patients (20 women & 19 men) and mean age at operation was 47.3 years (range of 32 to 76.1 years). Mean duration of follow-up was 39.14 months (range 5.21 -73.5 months). Thirty-one patients were diagnosed as Post laminectomy syndrome and 8 patients as post-discectomy syndrome.

The mean pre and post-operative ODI values were 54.13 and 29.14 respectively. The mean pre-operative VAS back and leg pain scores were 7.38 and 6.51 respectively. The mean post-operative VAS for back and leg pain scores were reduced to 4.05 (Pre-op:7.38) and 3.69 (Mean pre-op 6.51)respectively. The mean preoperative SF-36 bodily pain component score was 27.42 and the mean postoperative score was 40.50.

Four patients had uncomplicated dural tears that resolved completely. Two patients had superficial wound infection that resolved with oral antibiotics.

PLIF is one of the safe and effective treatment option for FBSS and it has shown good results in our series.

Pedicle screw constructs (PSC) in scoliosis are a recently established and widely accepted method of managing scoliotic curves posteriorly. There is a perceived improved coronal and rotational correction when compared to other posterior only constructs. With continued use of this method, the authors and deformity surgeons in general have become aware of persistent thoracic hypokyphosis.

This review of 3 years of scoliosis cases using PSC looks at four different implant strategies utilised to manage this problem and our current practice. These strategies were:

All titanium 5.5 mm rod diameter (Expedium, Depuy spine)

All titanium 5.5 mm rod diameter with periapical washers (Expedium, Depuy spine)

All titanium 6.0 mm rod diameter (Pangea, Synthes)

Titanium pedicle screws with 5.5 mm diameter cobalt chrome rods (Expedium Depuy spine)

We have reviewed our outcomes with these strategies with respect to thoracic hypokyphosis. Strategy 1 had the highest rate of hypokyphosis on postoperative radiographs. Strategy 4 seems to have the best correction of coronal and sagittal plane abnormality post operatively. As a consequence, our current practice is the use of titanium pedicle screws and 5.5 mm diameter cobalt chrome rods when managing scoliosis with a pedicle screw construct.

To compare the complication profile of a muscle splitting approach to the anterior cervical spine with previously described approaches.

The authors describe and compare the complications of an approach that exposes the anterior cervical spine by directly splitting the strap muscles in the midline with blunt dissection thereby potentially reducing iatrogenic complications.

A retrospective review of 62 operations to the anterior cervical spine, between 2002 and 2009. Indications: Fusion and arthroplasty procedures for brachalgia, axial neck pain and trauma.

The postoperative complications.

The complication rate was favourable compared to previously described approaches.

The muscle splitting approach to the anterior cervical spine has a low complication rate compared to previously described approaches, and allows the cervical spine to be approached with blunt dissection thereby potentially minimising iatrogenic approach related complications.

Back pain affects 70% of the population in developed countries and accounts for 13% of sickness absence in the United Kingdom¹. The clinical presentation might be taken less seriously and could result in significant morbidity and mortality. We did a retrospective observational study of patients admitted on an “acute” basis in our unit. Our aim was to identify the epidemiological proportion of patients who had significant life changing spinal conditions.

239 patients were admitted between January 2004 to December 2008 who presented with non traumatic back pain and related symptoms. The group of patients who had osteoporotic compression fractures were excluded. The mean age was 53.6 and patients were predominantly females. Disc protrusions and degenerative conditions accounted for majority of the patients. Cauda Equina Syndrome (CES) and Cord compressions together contributed to 7.9% and 8.7% respectively. The mean length of stay was 10.4 days and the average wait for MRI scan was 2.4 days.

Among the patients who present with back pain in the primary care setting, 3% have disc protrusions and 1% neoplastic lesions¹. But the epidemiological distribution among the back pain admissions in the hospital setting is not very clear. Medico legal costs especially with CES are quite substantial² and hence it would be useful to know the volume of patients with potential disabling lesions.

Our study reveals that a significant proportion of patients who had to be admitted with back pain and especially those having red flag signs have serious spinal pathologies. Early diagnosis and timely intervention could prevent unwarranted morbidity and mortality.

Thoracic spinal cord herniation is a relatively uncommon syndrome of anterior hemi cord dysfunction. However it has been reported in literature with increasing frequency over the last decade. Since the initial description of this clinical entity by Weitzman et al. in 1974, more than 100 cases have been described.

Although clinical features may vary considerably, as a clinical syndrome it is now widely recognized, and remains a potentially treatable cause of thoracic cord dysfunction.

Anterior spinal or thoracic cord herniation remains an uncommon yet a potentially treatable cause of thoracic myelopathy. Patients usually present in their middle ages, and literature suggests that there is a female predominance. The presenting symptom is usually a Brown Sequard syndrome, although other symptoms suggestive of thoracic cord dysfunction may be present. Although the symptoms are insidious the condition may lead to progressive paraparesis. The herniation is usually through a dural defect, the cause of which open to speculation. Operative treatment is advised, as the outcomes are generally favourable.

As part of a continued focus on this clinical syndrome we describe below a series of 4 patients with thoracic spinal cord hernias that presented to our neurosurgical service over the past 3 years and our experience in the treatment of this condition. Apart from one patient, in whom there possibly was an iatrogenic factor, the rest were all purely idiopathic. All the patients underwent surgical treatment and their outcomes were generally favorable.

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival.

We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years.

There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients).

Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3^rd of chondrosarcomas of the spine occured below 40 years of age and 3/4^th in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates.

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival.

The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry.

The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively.

Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series.

Chordomas are slowly growing, locally aggressive primary malignant neoplasms derived from primitive notochordal cells. They tend to occur at the extreme of ages and at the two ends of the spinal column. The purpose of this study was to evaluate the presentation, morphology and behaviour of 20 non-clival, non-sacral chordoma cases.

Details of 20 cases of histologically confirmed Chordomas of the mobile spine (Cervical-7, Thoracic-7, Lumbar-6) between 1967 and 2006, were extracted from the Scottish Bone Tumour Registry. The casenotes and radiographs were retrospectively reviewed.

Non-sacral chordomas comprised 48.7% (20/41 cases) of total chordomas registered. There was a slight feminine predominance (11/20 cases). Mean age was 58.1 years (range, 12 to 82 years). Progressively worsening back pain was the first symptom in all the patients. Seven had intra-lesional (five recurred), six marginal (1 recurred) and 2 wide resections (none recurred). Eleven of the twenty-one patients were treated with adjuvant radiation therapy. In five patients, the chordoma was inoperable and all but one were treated with radiotherapy. There were 2 recurrences in the group of patients treated without adjuvant radiotherapy.

Six patients (40%) developed local recurrences and 3 patients (15%) developed metastases. There were 4 survivors including one with local recurrence. Sixteen patients died including 3 with metastases, 7 with persistent primary disease, 1 with local recurrence and 5 with no evidence of disease or died of unrelated causes. Median survival was 19 months (mean-30.2 months), with 5- and 10-year survival rates 10% and 0.0% respectively.

We found that non-sacral/non-clival chordomas had a much poorer prognosis than published in the literature. Local recurrences occurred in 40%. Intra-lesional resection should be avoided as it is associated with 71.4% local recurrence in our series.