Many surgical approaches at decompression have been attempted for the thoracic outlet syndrome (TOS), but only the transaxillary and supraclavicular routes carry the best outcomes. More recently, a selective and tailored approach via the supraclavicular route has been favoured. We performed a retrospective review between 1978 and 1998, and report the outcome of the ‘’two surgeon approach’’ for TOS via the supraclavicular method.

An orthopaedic and vascular surgeon jointly conducted 30 operations for disabling symptoms relating to TOS in 27 patients (21F, 6M), mean age of 29 yrs (range 18–63 yrs), having performed the preoperative assessment in conjunction with a neurologist. In all cases, it was essential that patient selection for surgery was determined on clinical grounds rather than the presence of a cervical rib. Anterior scalenectomy was performed via the supraclavicular route except in one case where the infraclavicular route was utilised. Additional surgical procedures were carried out according to the underlying abnormalities, i.e. excision of cervical rib or band or medial scalenectomy. The first rib was always spared.

At mean follow-up of 37 mths (range 3-228 mths), 26/30 sides (87%) had excellent or good results. The results were fair or poor in three cases where scalenec-tomy alone was performed. There were no major complications and no patients required a re-operation. 24 patients (89%) returned to their previous lifestyle or occupation.

Our results suggest that, with a multidisciplinary assessment and two-surgeon team, good to excellent surgical outcomes can be achieved via the supraclavicular route without resection of the first rib. Instead of the current practise of routine transaxillary first rib resection, we recommend decompression via this approach with further procedures tailored to the abnormality identified.

Ongoing debate exists as to the integrity of the abdominal musculature unit in maintaining spinal support and stability. It is thought that the intra-abdominal pressure generated is important in spine stabilisation. Congenital aplasia of the abdominal musculature, i.e. prune belly syndrome (PBS), might therefore result in loss of spinal function and stability. We discuss the possible role of an intact abdominal musculature mechanism in maintaining spinal saggital balance and its relevance to low back pain with this case illustration of PBS. We also review the literature for the incidence of spinal deformities related to PBS.

We present a unique case of a 33-year-old male with PBS that resulted in loss of spinal saggital balance and development of a thoracic hypokyphotic deformity and thoracolumbar scoliosis. The patient also suffered from mild low back pain. Literature review suggests that secondary scoliosis appears to be the most commonly reported spinal deformity with up to 36% of cases being affected in one study.

Unequal compressive forces on the vertebral end-plates as a result of changes in static rib support, dynamic paraspinal muscle support, and changes in intrathoracic and intra-abdominal pressures may be the proposed mechanisms for the spinal deformities. Compensatory lumbar paraspinal over-activity due to the inability to generate normal intra-abdominal pressures because of a deficient abdominal wall musculature mechanism seems to be the plausible explanation for the thoracic hypokyphotic deformity observed. As a corollary, a failing abdominal wall musculature mechanism has been implicated in the risk for low back pain and its sequelae. Our case implicates that an intact abdominal musculature unit might be important in the maintenance of overall spinal function and stability. Maintaining normal intra-abdominal pressures, and the effects of abdominal exercises on this mechanism, i.e. training specificity, remain an important adjunct to our routine treatment of patients with low back pain.

Many pathological disease processes are manifested by abnormalities in cellular signalling caused by altered protein expression. Our aims, therefore, were to determine whether ‘’degenerative disc disease’’ results in 1) altered proteome expression and 2) such changes might be used as a marker for the disease process.

Using gel electrophoresis, we analysed the proteome expression of nucleus pulposus (NP) derived from patients with scoliosis (‘normal’) compared to degenerate samples from patients with 1) back pain undergoing spinal fusion (DDD) and 2) sciatica undergoing discectomy (herniated nucleus pulposus or HNP). Normal NP tissue was also obtained from organ donor patients with no previous history of back pain. All samples were investigated in duplicate. Protein concentrations were measured qualitatively by visual analysis in a blinded manner and categorised into high, medium, low or absent. The Kruskal-Wallis analysis of variance was sued to analyse the data. Subsequent proteins of interest were determined on N-terminal protein sequencing.

15 samples each were collected each from scoliosis, DDD, and HNP, but only 4 samples from the organ donor groups. One major protein band difference was observed whose molecular weight was 15 kDa and N-terminal sequence homologous with lysozyme C (lysozyme-C-like-protein - LCLP). DDD and HNP samples exhibited significantly reduced levels of LCLP compared to scoliosis (P< 0.0001). All NP from donor patients exhibited high levels of LCLP, but numbers were too small for statistical analysis. No statistical correlation existed between age and LCLP levels.

The true physiological roles of Lysozyme C remains unclear, but it is a known ubiquitous secretory and hydrolytic protein found in saliva, milk, cerebrospinal fluid and synovial liquid, and thought to function in primary immunity. LCLP loss in degenerate disc tissue might be due to 1) lack of production, 2) increased breakdown through a specific ubiquitin-linked pathway, or 3) polymerisation with tissue-specific amyloid deposition. The inflammatory effects within the NP related to localised LCLP-amyloid deposition offers a plausible hypothesis for patho-physiology of disc degeneration and discogenic pain. Until we determine the true nature and function of LCLP, we are no further in understanding the patho-mechanisms of disc degeneration. Moreover, LCLP loss in the NP of degenerate discs may provide a potential diagnostic marker for degenerative disc disease.

Routine use of Computed Tomography (CT) to evaluate discogram morphology is time consuming, costly and incurs additional radiation hazards. In our spinal unit, discography is routinely performed without the aid of CT. Discogram morphology for different stages of disc degeneration is evaluated using the modified Adam’s grading system on images obtained on fluoroscopy. Our aims were to assess the validity of the modified Adam’s grading system of discogram morphology, by assessing its inter- and intra-observer agreement.

We reviewed the discographic images (133 intervertebral levels) of 71 patients with chronic low back pain undergoing discography as part of a preoperative assessment between 1995 and 1997. Using the modified Adam’s grading system, three independent surgeon observers of three levels of experience (Senior Fellow, Senior and Junior residents) retrospectively evaluated the morphological appearance of each disc level in a randomized and blinded manner. Each observer was supplied with descriptions and illustrations of the 5 grades1, and each level was classified accordingly. The exercise was repeated three weeks later. The respective inter- and intra-observer agreements were calculated using the kappa statistic (Fleiss 1971) and generalized kappa statistic (Landis and Koch 1977).

The inter-observer agreement was excellent (kappa = 0.77; standard error = 0.054). The intra-observer agreement for each of the three observers was also excellent (kappa = 0.8, 0.8, and 0.85 with respective standard errors = 0.046, 0.049 and 0.042).

Significance and conclusions: The inter- and intra-observer agreement and therefore the reliability of the modified Adam’s grading system is excellent. This classification is easy to apply and has a high degree of reproducibility amongst observers with different levels of spinal experience. In view of the high reproducibility, we recommend the Adam’s classification for the grading of discogram morphology. The routine use of computed tomography with the concomitant radiation exposure and additional cost would seem not to be justified.

86 children with 87 lateral condyle fractures were reviewed. Excellent clinical outcomes in 88.9% of Type 1 undisplaced or < 2mm displaced fractures treated by simple cast immobilisation.

In the Type 2 displaced fractures (2–3mm) treated by cast immobilisation, the risk of secondary displacement was 44%

Conclusion: Undisplaced or < 2mm displaced fracture can be treated conservatively in plaster immobilisation.

For 2–3mm displaced fracture, we recommend percutaneous pinning or open reduction and Kirschner wire fixation.

For displaced or rotated fractures, the fragment should be reduced anatomically and fixed with K wire until radiological union.