Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients.

A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted.

Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively.

In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics.

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

Aims

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected.

Abstract

Abstract

Abstract

Aims

To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis.

Aims

Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality.

Aims

We present a case series of five patients who had revision surgery following magnetic controlled growing rods (MGCR) for early onset scoliosis. Metallosis was found during revision in four out of five patients and we postulated a mechanism for rod failure based on retrieval analysis.

Aim:

To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS).

Aim:

To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS).

Assessing the efficacy of cervical orthoses in restricting spinal motion has historically proved challenging due to a poor understanding of spinal kinematics and the difficulty in accurately measuring spinal motion. This study is the first to use an 8 camera optoelectronic, passive marker, motion analysis system with a novel marker protocol to compare the effectiveness of the Aspen, Aspen Vista, Philadelphia, Miami-J and Miami-J Advanced collars. Restriction of cervical spine motion was assessed for physiological and functional range of motion (ROM).

Nineteen healthy volunteers (12 female, 7 male) were fitted with collars by an approved physiotherapist. ProReflex (Qualisys, Sweden) infra-red cameras were used to track the movement of retro-reflective marker clusters attached to the head and trunk. 3-D kinematic data was collected from uncollared and collared subjects during forward flexion, extension, lateral bending and axial rotation for physiological ROM and during five activities of daily living (ADLs). ROM in the three clinical planes was analysed using the Qualisys Track Manager (Qualisys, Sweden) 6 Degree of Freedom calculation to determine head orientation relative to the trunk.

For physiological ROM, the Aspen and Philadelphia were more effective at restricting flexion/extension than the Vista (p<0.001), Miami-J (p<0.001 and p<0.01) and Miami-J Advanced (p<0.01 and p<0.05). The Aspen was more effective at restricting rotation compared to the Vista (p<0.001) and Miami-J (p<0.05). The Vista was least effective at restricting lateral bending (p<0.001). Through functional ROM, the Vista was less effective than the Aspen (p<0.001) and other collars (p<0.01) at restricting flexion/extension. The Aspen and Miami-J Advanced were more effective at restricting rotation than the Vista (p<0.01 and p<0.05) and Miami-J (p<0.05). All the collars were comparable when restricting lateral bending.

The Aspen is superior to, and the Aspen Vista inferior to, the other collars at restricting cervical spine motion through physiological ROM. Functional ROM observed during ADLs are less than those observed through physiological ROM. The Aspen Vista is inferior to the other collars at restricting motion through functional ROM. The Aspen collar again performs well, particularly at restricting rotation, but is otherwise comparable to the other collars at restricting motion through functional ranges.

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury.

We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol.

This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application.

Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative.

We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries.

Introduction

The British Scoliosis Society published a document in 2008 which set out the minimum standards for paediatric spinal deformity services to achieve over a period of time. But how do the UK paediatric spinal deformity centres measure up to these benchmarks?

Purpose

Comparison between Aprotinin and Tranexamic acid on blood conservation in scoliosis surgery.

Purpose

Retrospective review of growth sparing spinal instrumentation.

Purpose

To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching.

Objective

To compare the effectiveness of the Aspen, Aspen Vista, Philadelphia, Miami-J and Miami-J Advanced collars at restricting cervical spine movement in the sagittal, coronal and axial planes.

Introduction

Reported incidence of DVT after spinal surgery ranges from 0-15% and PE 0.5-2.7%. Theoretically, manipulation of the vessels and venous stasis caused by retraction during anterior lumbar inter-body fusion may increase the propensity for thrombosis. The reported incidence of DVT and PE following major abdominal and pelvic surgery are high (up to 23%) and all these patients routinely receive chemical prophylaxis.

Purpose of Study

To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines

Introduction

Halo traction, either on bed or with an accompanying vest is used commonly in Spine surgery, in a variety of clinical situations. The pins are inserted into the skull in safe anatomic zones, using wrenches that are either pre-torqued or exhibit a torque gauge to allow measurable torque application. A torque of 6 – 8 inch pounds is considered ideal for optimal pin tightening. Lesser torques may hypothetically lead to pin loosening and pin track infections, while, excessive torques could lead to pin penetration through the skull.

Aim of Study

To highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury.

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.

Purpose

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

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.

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.

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.

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.

Methods: 229 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.

Results: Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male -5 (27.7%), female- 13(72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.8%) patients.

Discussion: Previous studies (Fisk et al, 1978; Mau H 1977) 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, 2009). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

Conflicts of Interest: none

Source of Funding: none

We aimed to evaluate the effects of implementing blood conservation strategies on transfusion requirements in adult patients undergoing scoliosis correction surgery. We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients had a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, anti-fibrinolytics used and blood transfused was noted.

50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Antifibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10 (20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

In conclusion, the use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures. In our unit we do not have blood cross matched for anterior surgery alone.

Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following arthrodesis with HMA (Hollow modular anchorage; Aesculap Ltd, Tuttlingen) screws.

Fifteen consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The HMA screws packed with bone substitute were implanted percutaneous under fluoroscopic guidance.

The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post-operative or radiological complications.

Percutaneous HMA screws are a satisfactory way to achieve sacroiliac stabilisation.

Background: The simultaneous occurrence of spina bifida occulta (SBO) and spondylolysis has been noted previously. The occurrence of SBO and spondylolysis are approximately 17% and 5% respectively.

Aims: The aim of this study was to determine the incidence of SBO when a symptomatic spondylolysis has been proven.

Method: Analysis of four years of lumbar spine CT scans was performed. Patients with spondylolysis or spondylolisthesis caused by a pars defect were identified. These patients’ CT images were then reviewed to establish the patients who also had SBO.

Results: In this unit 650 CT scans of lumbar spines were performed in the last five years. Of these scans 100 (15%) were found to have a pars defect. The average age was 34.6. On CT 30 (30%) patients were shown to have SBO. Of the total 23 were under 18 years old and 13 (56%) of these patients had SBO associated with the spondylolysis. In the over 18 year olds 21 (27%) patients had SBO associated with spondylolysis.

On review of the 550 other scans the average age was 51.9 years old. The incidence of SBO within this group is 10%. Only 6% of these patients were under 18. Out of these 33 patients 30.3% (10 patients) had SBO. Over 18 the incidence of SBO was only 8.5%.

Conclusions: Our results indicate that the occurrence of SBO within the group with a spondylolysis is much higher than in the group where no spondylolysis is present. There is higher incidence of SBO in the younger patients with spondylolysis. 56% of paediatric patients with symptomatic spondylolysis will have SBO. Clinicians should be aware of this fact preoperatively to decide on the technique of repair of the symptomatic lysis.

Introduction: Spinal surgical procedures are associated with significant morbidity. It is vital the patients are aware of the potential complications and the implications. The General Medical Council published guidelines regarding consent in June 2008.

Aim: To examine the adequacy for consenting for spinal surgical procedures and focussing on documentation of serious risks.

Methods: Case notes of seventy consecutive patients who had undergone spinal surgery were retrospectively reviewed. The consent forms were examined for documented procedures, complications, grade of the consenting member and timing of the consent.

Results: The documented procedure on the consent form and the operation sheet matched in all seventy cases (100%). Consent was taken by the consultant in 50% of the patients, 30% were consented by middle grade doctors and 20% were consented by the junior doctor. The consenting person was present at the procedure in 63% of the cases. Sixty percent (60%) of the patients were consented in the pre-admission clinic, 23% were consented on the day before the procedure and 17% were consented on the day of the procedure. Common and serious complications such as infection (84%), bleeding (76%), pain (67%), bladder and bowel problems (84%), paralysis (70%) and nerve root damage (67%) were clearly documented.

Conclusion: Two-thirds of the patients are given adequate information to obtain informed consent in the pre-admission clinic. Majority of the patients are aware of the common and the serious risks associated prior to the procedure.

Interests: None

Ethics approval: None

Background: Satisfaction following anterior and/or posterior spinal fusion varies greatly between individuals. The aim of this study was to assess patient satisfaction with the post-operative scars following surgical correction of scoliosis.

Methods: Prospective study; 31 patients (range 10–37 years), minimum of 2 months post-operation, interviewed in clinic or over the telephone using a questionnaire.

Results: Overall, 18 (58%) patients were disappointed with their scar; it was not what they expected, Patients with anterior scars or both anterior and posterior scars were the most disappointed groups.

39% of patients felt they were inadequately informed or not informed of the nature of scar. However, over 50% of those who had a specialist spinal nurse (SSN) consultation reported the scar to be as they expected. Scar length was the main source of disappointment. 55% reported their scars as being raised (keloid), particularly at the ends. Scar colour and shape was an issue for 23%, whilst 39% experienced prolonged healing. 19 patients had a pre-op consultation with the SSN, 11 did not get this opportunity, 1 declined.

Conclusion: Clearly there’s a need for improved education and understanding with regard to the nature of the scoliosis surgical scar(s). Input from a SSN is important and surgeons must clarify exactly what they mean when discussing operations with patients. This could be done with the aid of pictograms or leaflets detailing issues discussed in consultations along with the opportunity to meet patients who have already had surgery. These measures may lead to increased patient satisfaction with surgery.

Ethics approval: Audit

Interest Statement: None

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.

Methods: 229 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.

Result

Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male-5 (26.3%), female- 4(73.6%). Majority of the patients with were females (72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.7%) patients.

Discussion

Previous studies (Fisk et al, 1978; Mau H 1977) 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 (Jon R. Davids et al, 2004). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

This study aims to evaluate the accuracy of sheer off self limiting screw drivers and to assess repeatability with age.

It has been reported that overzealous tightening of halo pins is associated with co-morbidity. Our unit has recently received a tertiary referral where the patient over tightened a pin leading to intracranial haematoma, hence our interest in this subject. The torque produced by six new and nine old screw drivers was tested using an Avery Torque Gauge and a Picotech data recorder. These devices are designed to produce a torque of 0.68 Nm, any greater than this is potentially hazardous. Accepted error for each device was +/− 10%. The average torque produced by the new screw drivers was 0.56 Nm with a range of 0.35–0.64 Nm (SD 0.120). The older screw drivers produced an average torque of 0.67 Nm ranging from 0.52–0.85 Nm (SD 0.123).

In conclusion, sheer off self limiting screw drivers are not accurate devices. The older devices are more likely to produce a torque exceeding a safe range and therefore we would recommend the use of new devices only.

Ethics approval: none audit.

Interest statement: none local grant.

Background: It remains unclear and controversial whether preoperative magnetic resonance imaging (MRI) in patients with adolescent idiopathic scoliosis (AIS) should be mandatory.

Aim: (1) To review our own practice, (2) conduct a national survey of United Kingdom Consultants, and (3) to perform a literature review.

Methods: Our own practice was established by identifying patients with AIS and examining whether an MRI scan was performed preoperatively. A survey of Consultants practice in the UK (British Scoliosis Members) was conducted by either an e-mail or telephone conversation. Finally, a literature survey was performed to establish current views.

Results: 118 patients with AIS were identified between 2003 and 2007. 78% of these patients underwent pre-operative MRI scans. Neural axis abnormalities were found in 8% of these patients. They included syrinx’s, chiari malformations, tonsillar herniation, cord tethering, central canal dilatation and undiagnosed spina bifida. Only 1 patient required intervention by the neurosurgeons. 92% of respondents to the national survey routinely performed preoperative MRI scans. The literature was not conclusive with regards to mandatory preoperative imaging.

Conclusion: Despite the literature showing little evidence, our survey shows a widespread consensus in clinical practice across the UK that routine preoperative MRI should be performed from a risk management viewpoint. It is mandatory in our unit to perform pre-operative MRI scans on all patients with AIS and would recommend that this becomes standard practice in all other units.

Ethics Approval: None/Audit

Interest Statement: None

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.

Introduction: Scoliosis surgery involves major blood loss, at times exceeding estimated blood volume.

Aim: To evaluate the effects of implementing blood conservation strategies (including cell salvage, controlled hypotension and anti-fibrinolytic drugs) on transfusion requirements in adult patients undergoing scoliosis correction surgery. To establish a protocol for cross matching of blood.

Study Design: We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients were anaesthetised by the same anaesthetist who implemented a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, antifibrinolytics used and blood transfused was noted.

Results: 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Anti-fibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

Conclusion: Use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures.

In our unit we do not have blood cross matched for anterior surgery alone.

Background: Radicular pain has been reported even in the absence of a compressive lesion. It has been postulated that annular tears provide a conduit for pro-inflammatory substances, which can leak around the nerve root causing radiculitis. A link between the side of back pain and the side of the annular tear has been reported.

Objective: To establish whether the side of the annular tear may influence the side of the leg in a non-compressive setting.

Methods and patients: We identified 121 patients from the patients referred to our unit with back and radicular leg pain. The mean age of the cohort was 50 yrs and 49% were male. All these patients were investigated with an MRI scan that demonstrated no compression of the nerve root. We used strict exclusion criteria to exclude the patients with any neural compression, previous lumbar operation, degenerative deformity or an associated pathology such as peripheral neuropathy.

Results: The annular pathology was described as annular tears (47 patients) and non compressive disc bulges (106 patients). The odds ratio for the concurrence of an annular tear causing ipsilateral leg pain is 1.05 and for a non-compressive disc bulge causing ipsilateral leg pain is 2.14

Conclusion: A non-compressive disc bulge is more likey to cause radicular symptoms than an annular tear. Though, both these annular lesions can cause ipsilateral nerve root symptoms.

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix.

Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control.

The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs.

Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology.

We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.

Anterior Lumbar Interbody Cages are used to recreate the lumbar lordosis in scoliosis surgery as anterior instrumentation is usually kyphogenic. We report two cases in which an anterior release was performed and interbody cages were used.In both these patients the cage was displaced anteriorly by an incorrectly positioned pedicle screw during posterior instrumentaion. In one case the cage was retrieved and correctly repositioned from the back using a TLIF approach, in the other this was noticed only post-operatively and patient needed another anterior surgery. We recommend a lateral Image Intensifier screening for combined anterior and posterior cases in which anterior cages are used in addition to posterior pedicle screws to prevent this complication.

Objective: To do assess changes in patients’ symptoms and the operative plan.

Materials and methods: 147 patients on a spinal surgery waiting list were assessed at a mean wait of 15.8 ± 1.3 months. 89 (61%) were male and 58 (39%) were female at a mean age of 49.7 yrs (16–78). 123 patients had a degenerative condition (20 cervical; 03 lumbar); 20 patients were seen for scoliosis; 2 with a post-traumatic kyphosis and 1 each with ankylosing spondylitis and a psudarthrosis.

Outcomes assessed: Changes in patients symptoms; changes from the initial operative plan when listed; requirement for re-imaging due to the wait.

Results: 31 patients reported improved symptoms at the re-assessment, while 96 were worse off and 20 were unchanged. 137 had axial pain when listed which changed to 116 at review (p=0.0018). 130 had radicular pain when listed which improved to 80 on re-assessment (p< 0.0001). However 19 reported an increase in the axial and 17 in the radicular symptoms. 71 patients (48.3%) required to be re-imaged at the re-assessment due to changes in the clinical picture. 42 patients received the procedure as originally listed. 30 patients were taken off the list, 24 received a different operation, and 38 had an interim or a definitive needling procedure while 13 await a re-assessment.

Conclusions: On the basis of the observations on our cohort, 1 in 5 operations were cancelled; 65% had an increased severity of the symptoms and just 1 in 3 patients were operated as planned while 48% required re-imaging. A long wait inevitably leads to changed symptoms and a review of these patients is mandatory. The review and the re-imaging adds to the burden on the already over-loaded system.

Objective: To assess the temporal geometric sagittal profile changes on serial radiographs of fractures of the thoracic and thoraco-lumbar spine.

Materials and methods: We have included 103 patients with thoracic or lumbar fractures were treated at our unit between June 2003 and May 2006. The patients were suitable for non-operative treatment. The mean age of the cohort was 46.9±2.4 (16–90). The sex distribution was equal. 94 patients had a single level lesion. 19 fractures were in the thoracic spine; 64 in the thoraco-lumbar (T11-L1) and 29 between L2 and L5. The radiographs were scored using the AO classification by 2 senior orthopaedic trainees. The radiographs were analysed at the Spine Research Laboratory. The results were computed using Stat, a statistical software.

Results: The changes were assessed over a mean period of 5.6 mo (range 1–49 mo; 95% CI 4.1–7.1 mo). Weighted kappa score of 0.58 was computed for the primary fracture type and 0.22 for the fracture sub-types. The inter-observer rater agreement was similar to that reported in literature. 7 patients showed a significant collapse. We report the association between the fracture types and the extent of collapse. We have also assessed the association between the medium to long term symptoms, the fracture types and the extent of collapse at the fracture sites and the adjacent disc.

Conclusion: Some fracture sub-types are more likely to collapse and cause long term symptoms. Identifying these fractures at the outset would help clarify surgical indications.

Objective: To assess the correlation between the side of the annular pathology and the radicular symptoms, in the absence of a compressive root lesion.

Materials and Methods: 121 patients underwent MRI scan fro axial back and radicular symptoms. The mean age was 49.9 yrs (24–80). The sex distribution was equal. We excluded the patients that had a compressive lesion, previous operations, spinal deformity, spondylolyses, an underlying pathology (tumour, trauma or infection) or a peripheral neuropathy. Annular pathology was documented as annular tear or a non-compressive disc bulge with its location and side. We also recorded marrow endplate changes and facet arthrosis.

Results: Bilateral radicular symptoms were reported in 16 (13.2%): right side in 33 (27.3%) and left in 47 (38.8%) patients. Additionally, 82 patients (67.8%) had axial back pain. 33 patients (27.3%) were noted to have a right sided annular pathology (tear or bulge) and 72 (59.5%) had a left sided annular lesion. 21 patients (17.4%) had a central annular tear and 43 (35.5%) had a generalised disc bulge. 14 patients (11.6%) with right sided symptoms also had annular pathology, while 38 patients (31.4%) with left sided symptoms had a left sided annular lesion. There was no statistical correlation between the side of symptoms and the side of the lesion (r = −0.00066, p=0.994), any particular annular pathology (annular tear r=0.085, p=0.35; disc bulge r-0.083, p=0.36). There was no correlation between the axial back pain and the annular pathology (r=0.004; p=0.97) and facet joint or marrow end plate changes (r= −,29, p=0.76).

Conclusions: Although annular pathology can cause the radicular symptoms, our results suggest that they do not influence the side of the symptoms.

Introduction: Sacroiliac joint pathology can contribute to lowback pain and sciatica. Its frequency and significance is controversial.

Aims: The purpose of this study is to evaluate the incidence and clinical significance of positive SI joint pathology on MRI scans.

Methodology: 353 MRI reports and scans carried out over a one year period for backpain and sciatica were reviewed. Demographic data and clinical notes of patients who had positive SI joint pathology on MRI scans were analysed. Correlation between clinical suspicion of SI joint pathology and MRI findings was studied.

Results: 12 scans showed pathology in the SI joint, an overall incidence of 3.3%.8(66%) were males and 4(33%) females. Only 4(33%) of these patients had Plain Film abnormality. Average age of 41.2 years (33–54). One patient was known case of Ankylosing Spondylitis. Other positive pathology included oedema, sclerois and bridging osteophytes. Clinicians requested inclusion of SI joint in 43 patients. 8 of these were positive, an incidence of 18.6%. In 130 patients, the SI joints were imaged as routine. This yielded positive pathology in 4 patients (3%).

Conclusion: Our study concludes that 18.6% of patients who are suspected to have SI joint involvement clinically have positive pathology on MRI scans.

Routine inclusion of imaging of the SI joint as part of lumbosacral spine MRI for back pain and sciatica shows only 3% positive results.

SI joint should be imaged only if clinically suspected.

Aim: To assess if commonly used scoliosis instrumentation activates metal detectors at airport security gates.

Methods: 20 patientswho had travelled by air following scoliosis surgery were included. The type of instrumentation, number of journeys, body mass index and whether the alarm was triggered off by the airport security detector was recorded. We asked the patients opinion regarding provision of documentary evidence of surgery.

Results: 10 patients had posterior instrumentation, 5 patients -Paediatric ISOLA,4 patients had anterior instrumentation and one patient, anterior and posterior instrumentation. 12 patients (60%) had travelled more than four times by air following surgery corresponding to 48 passes through an airport archway detector.5 patients out of 20 had set off the alarm while passing through the metal detector everytime of which 4 had posterior instrumentation and 1 anterior instrumentation. None of the patients with ISOLA instrumentation set of the alarm. Two patients had set off the alarm every time they passed through the metal detector and both of them had posterior instrumentation. 14 patients(70%) suggested that we should provide documentary evidence of surgery to avoid delays in the airport security check. 25 % of patients set of the metal detector alarm following scoliosis instrumentation.

Conclusion: Patients with posterior instrumentation are more likely to set off the alarm compared to patients with ISOLA instrumentation. It is important to be aware that scoliosis instrumentation can activate airport archway detectors in our present security climate and to provide documentation to patients in order to avoid embarassment and delays.

Introduction: Scoliosis Nursing service was introduced at the Cardiff Spinal Unit in 2003 as part of a multi-disciplinary team to improve quality of care for the patients and their families.

Background: This nurse is a point of contact at pre-admission and discharge. She co-ordinates the peri operative care and liases with other team-members including physiotherapists, occupational therapists and dieticians. Information regarding type of surgery, pain management, wounds/dressings, investigations is offered.

Aims and Objectives: To assess patients’ and families perception and satisfaction with the various aspects of care provided by the Scoliosis Nurse.

Methods and Materials: From 2005 to 2006, 30 consecutive patients and families who had seen the Scoliosis Nurse filled a questionnaire. 25 questionnaires were completed. Response was collated by an independent observer.

Results: All (100%) respondents felt that the presence of a nurse in clinic was beneficial. (100%) reported that they had received adequate information and literature. 66% of the patients felt a pre admission ward visit would be beneficial. 63% felt that further information about discharge and aftercare would be helpful.

Conclusion: Thus the Scoliosis Nurse was perceived to be beneficial by the patients and the family. Based on the abovefeedback the patient Information booklet has been updated.

Paravertebral anaesthesia is a particularly effective, safe and reliable option in scoliosis patients undergoing anterior release in whom percutaneous epidural placement may be difficult to perform. A recent systematic review and meta-analysis of randomized trials has demonstrated that whilst paravertebral block and thoracic epidural insertion provide comparable pain relief after thoracic surgery, paravertebral block placement is associated with a better side effect profile, including a reduction in pulmonary complications, hypotension, nausea and vomiting and urinary retention. We describe a case of a 16 year old female patient who underwent staged correction of her thoracolumbar scoliosis. A paravertebral catheter was inserted under direct vision for continuous infusion post operative analgesia following the anterior release. 48 hours after surgery a swelling was noted in the groin, which was confirmed with ultrasonography as a fluid collection. The swelling resolved upon removing the paravertebral catheter. This suggests that it was caused by the local anaesthetic fluid tracking along the psoas muscle. Retroperitoneal infections, venous thrombosis, femoral hernia, femoral artery aneurysm and inguinal lymphadenopathy are other differentials. Ultrasonography was a fast and sensitive investigation to rule out these differentials and determined that fluid communicating with the abdominal cavity was the cause for this swelling. The infused local anaesthetic had tracked down into the femoral triangle and the swelling resolved upon cessation of the infusion.

Background: Thoraco-lumbar fractures without a neurological deficit are usually suitable for non-operative treatment. The main area of clinical interest is the deformity at the injured levels. The deformity may be evident at the time of presentation, though could be expected to progress in time.

Objective: Accurate assessment of the temporal behaviour in the geometry of the injured segments in non-operatively treated thoracolumbar fractures with normal neurology.

Materials: 102 patients with thoracolumbar fractures without a neurological deficit were treated non-operatively at our unit between June 2003 and May 2006. The mean age of our patient cohort was 46.9 yrs (16–90 yrs). Strict criteria were followed to determine suitability for non-operative treatment. Supine radiographs were performed at the initial assessment. Erect radiographs were performed when trunk control was achieved and at follow-up assessments thereafter.

Methods: Quality Motion Analysis (QMA) software (Medical Metrics Inc, Houston, Tx) was used to measure rotational and translation changes between the end plates using a validated protocol. The radiographs were standardised for magnification and superimposed from different time points. Transformation matrices were used to track the changes. The AO classification was used to classify the fractures by 2 independent observers.

Results: A median of 4 radiographs were analysed for each patient (range 2–9), at a mean follow-up of 5.6 mo (95% CI 4.1–7.1 mo). 92% of the cohort had sustained a 1 level injury. 76% of the injuries were between T12 and L2; 19% were in the thoracic spine. An inter-observer rating of 0.58 was obtained for the classification of the primary fracture type. The mean rotational change was −1.4855° ± 0.248° (95% CI: −0.994° to–1.976°). The mean anterior vertebral body height collapse was −4.3444° ± 0.6938 (95% CI: −2.695 to −5.724). The mean posterior vertebral height collapse was −0.7987 ± 0.259 (95% CI: −0.284 to −1.313).

Conclusions: We report the use of QMA software to track changes in the vertebral body geometry accurately. This has implications on the clinical aspects of management of thoracolumbar fractures based to progression of deformity that could be explored in future studies.

Background data: The Paediatric Isola system uses the philosophy of torsion-countertorsion force as a means of scoliosis correction. It aims to maintain this correction till such time that definitive fusion can be carried out.

Aim: This is a retrospective case series of our experience with the Paediatric Isola system and we evaluated the results of this system in the treatment of Scoliosis of various etiologies.

Methods: Twenty –one children,5 with neuromuscular,1 with Ehler-Danlos,5 with idiopathic,3 syndromic and 7 congenital treated with the Isola Instrumentation were studied.

Average age was 6.5 years(2–12). Average follow-up was 24 months (6m-36m).

Results: The average Cobb angle was 52° before surgery, 33.7° after surgery (64 % correction) and 32.5° (62.5% correction) at latest follow-up. The mean apical vertebral translation was 86% and 84% at post-op and latest follow-up. Stabilisation was most commonly perfomed from T2 to L4/L5. Three patients had implant complications, two had deep seated wound infections which necesssiated removal of implants in one case. Five of these patients have gone on to definitive fusions. Curve correction was best for primary thoracolumbar curves and lumbar curves. 2 patients with thoracic curves did not maintain correction.

Conclusion: The Paediatric Isola system is a safe and effective instrumentation in early management of a difficult and challenging sub group of scoliosis patients.

Background data: Previous studies have questioned the quality of information available on the internet. Internet research has proven to more prevalent among scoliosis patients as compared to other orthopaedic conditions.

Aim: Scoliosis websites identified by commonly used search engines were assessed for quality and medical accuracy.

Methods: The word scoliosis was entered into top six search engines and Websites ranked according to frequency. Five websites from the worldwide web and five from the UK only search were evaluated by medical professionals – 4 spinal consultants, 2 registrars, 3 nurses and 1 physiotherapist. 10 patients/carers who had scoliosis surgery also assessed these sites. A scale of 1 to 5 was used for ease of understanding, reliability, clinical correlation, adequacy and links and average score calculated.

Results: None of the top five UK websites figured in the top 5 WWW searchs. Scoliosis research society (SRS) and American Academy of Orthopaedic Surgeons (AAOS) website scored the highest by clinicians and patients in the www list. From the UK list, SAUK website scored the highest with both groups followed by Great Ormond Street Hospital (GOSH) website. We compared the assessment of websites by a healthcare professionals and by patients who had undergone treatment and showed no statistical difference in the scoring.

Conclusion: As treating clinicians it is necessary to educate patients by guiding them to reliable internet sites like SAUK and SRS.

Objective: Prolonged waiting time after being referred for a specialist opinion has plagued the NHS despite pressures to deliver optimum healthcare. We have assessed changes in clinical situation in patients referred to a spinal service while awaiting the first assessment.

Materials & Results: 89 patients were referred to our unit between Jan 2001 and December 2004. The gender distribution in this cohort was equal and the mean age was 50.7 yrs. The mean delay for being seen in the clinic was 28.4 mo (16–58 mo). Significant changes in the symptom pattern were noted in 46 patients, of which 8 patients reported radicular symptoms on a different side. In addition, 7 patients experienced an increased severity in the existing symptoms. 43 patients had been referred to us with an MRI. However due to the delay, 20 of these patients required re-scanning. Following the clinical assessment 25 patients were referred for Physiotherapy, 4 patients required a further clinical review and 44 patients were referred for further imaging.

Conclusion: The problem of excessive out-patient waiting time results in changes in symptom patterns and an increase in the severity of existing symptoms. The changes frequently results in an increased requirement of re-imaging.

Introduction: Restoration of vertebral height for burst fractures can be achieved either anteriorly, posteriorly or combined.

Aim: To biomechanically assess and compare stiffness of 1) posterior pedicle screws with Synex, 2) Synex+ Double screw+rod Ventrofix 3) Synex+ Double screw+ Single rod and 4) Synex+ Single screw+ Single rod in reconstructing an unstable burst fracture following anterior corpectomy.

Method: Fresh frozen calf lumbar spines (L3–L5) were dissected and L4 corpectomy performed. L3 and L5 were mounted on a plate and fixed. Loads were applied as a dead weight of 2Nm. The range of movement was measured using the Qualisys motion analysis system using external marker clusters attached to L3 and L5. Bony landmarks were identified with marker clusters as baseline. The movement was measured between the 2 marker clusters.

Five specimens were implanted for each group 1) with pedicle screw (into L3 and L5) and tested with/without Synex (expandable) cage anteriorly, 2) implanted with a Synex cage and Double screw+rod Ventrofix system, 3) Synex cage and Double screw+ Single rod Ventrofix construct and 4) Synex cage and Single screw+ Single rod Ventrofix system.

Results: Reconstruction of the anterior column with the combination of Synex and double rod Ventrofix produces a stiffer construct than the pedicle screw system in all planes of movement (p= 0.001 in rotation).

The double screw/ single rod system is less effective than the Ventrofix System but is comparable to the pedicle screw construct.

The single screw/ single rod construct leads to unacceptable movement about the axis of the inferior screw particularly in extension with a ROM much greater than the intact spine (p< 0.001)

Conclusion: Thus biomechanically we recommend Synex and double rod Ventrofix construct to reconstruct the anterior vertebral column following corpectomy for unstable burst fractures.

Aim: To determine the incidence of adjacent level osteophytes in patients who have had anterior cervical fusion using an anterior cervical plate as compared to those who are fused without an anterior cervical plate.

Design: We retrospectively reviewed the lateral radiograms of sixty two patients who have had an anterior cervical fusion with a minimum follow up of twelve months.

Materials and methods: We looked for the development of adjacent level osteophytes in these patients at their final follow up, which was generally at the time radiological fusion. There were 27 patients in the first group who had an anterior cervical plate used to fix the vertebrae in addition to the Cervios cage, while the 35 patients in the second group in whom only a Rabea cage was used for the fusion. The mean follow-up was 20.6 months (range 12–48).

Results: 64.3% of the patients who had an anterior cervical plate developed adjacent level osteophytes while none of the patients who have had the fusion without the cage developed the osteophytes.

Conclusion: We found the patients who had an anterior cervical interbody fusion using a plate had a significant risk of developing adjacent level osteophytes while this is not seen in patients who do not have the plate for the fixation.

Objective: To investigate the clinical outcomes, and the requirement of surgery following selective nerve root block performed for cervical radicular pain in patients with MRI proven disc pathology.

Methods: Thirty consecutive patients with cervical radiculopathy and correlating MRI pathology were studied. Mean age of patient was 46yrs (range 28–64yrs). Twenty nine of the thirty patients also complained of associated neck pain. All underwent fluoroscopically guided, selective cervical nerve root block with steroid (20mg Depomedrone) and local anaesthetic (0.5ml Bupivo-caine 0.25%). Radiographic contrast was used to confirm needle position. All procedures were conducted by the same clinician.

Pre and post procedure pain and physical function scores were noted using the standard SF 36 questionnaire, as well as whether subsequent surgery was required. Mean follow up time was seven months (range 2–13 months).

Results: 81% of patients reported an improvement in arm pain, and 66% in neck pain following the procedure. 77% of patients had an improvement in pain score (mean improvement 16 points). 68% of patients had an improvement in physical function score (mean improvement 20 points). At the time of follow up only one patient had undergone surgery for cervical radicular pain.

Conclusion: This study suggests that fluoroscopically guided selective nerve root block is a clinically effective interventional procedure in the management of cervical radicular pain, and may prevent the need for open surgery.

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards.

A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.

Patients admitted to trauma wards are routinely screened for MRSA pre-operatively. The majority of them have implant surgery before the screening results were available. The aim of our study was to identify the incidence of MRSA wound infection in these patients and their outcome following it.

We randomly reviewed 40 patients who were colonised with MRSA pre-operatively and have had implant surgeries. The case notes, drug charts and the microbiology were reviewed to identify the incidence of MRSA wound infection and its outcome in these patients. The place of residence, site of colonisation and the treatment given were also considered.

70% of the patients were admitted from home and 20% had previous admission within one year. The commonest site colonised is the nose (50%) followed by the perineum in 20%. Multiple sites were colonised in 10% of the patients. Only 50% of them with positive nasal MRSA were given nasal bactroban and chlohexidine wash was given in only 70% of them with MRSA colonisation in other areas. 22.5% (9/40) of the patients developed MRSA infection post operatively and they were treated with vancomycin or teicoplanin. Wound debridement and washout were done in 67.5%. 75% of the MRSA infected wound healed well with no MRSA in the wound site after treatment. 25% of the MRSA infected wounds had persistent MRSA in the wound.

As per our study the incidence of MRSA wound infection in patients colonised pre-operatively is about 22.5%. Most cases seem to heal well without much complication with appropriate antibiotics and wound care.

Background: Although either anterior or posterior corrective scoliosis surgery has been reported in Jehovah’s Witnesses, we did not find any reports of single stage combined anterior and posterior scoliosis surgery being done in these patients. We report our experience in one such case.

Methods: This is a case report of a 14 year old female Jehovah’s Witness who had cerebral palsy with total body involvement presented with right sided thoracolumbar scoliosis. She was wheel chair bound and was being treated in a spinal brace. She had a partially correctible thoracolumbar curve from T5 to L2 measuring 94°, which reduced to 74° in brace. Her parents were counselled regarding scoliosis surgery. They consented for the surgery and also signed a special consent form for Jehovah’s witnesses specifying that they would prefer their child not to have transfusion of blood or blood products under any circumstances. They were explained that in case of excessive bleeding, further surgery may need to be deferred.

Results: Although her pre-op Haemoglobin was 14.3 g/dl, she was given oral ferrous sulphate because of low serum ferritin level (34 mcg/L). After induction of anaesthesia, intra operative hemodilution was performed using 900 ml of crystalloid. During surgery aprotinin infusion was used with controlled hypotension and cell salvage. Anterior release was performed followed by posterior instrumentation. The operation lasted for 8 hours. Central venous pressure and arterial oxygen saturation remained stable throughout the operation. She recovered well following surgery, with post-operative haemoglobin of 9.8 g/dl and was discharged on the7th post-operative day. Oral iron supplementation has been continued after surgery.

Conclusion: Due to religious reasons, Jehovah’s Witnesses do not accept transfusion of blood and blood products, which makes major surgery like scoliosis correction difficult as it involves a significant amount of blood loss. Such patients benefit from pre-operative iron supplementation, pre-operative haemodilution, intraoperative hemodilution, cell salvage, use of Factor 7, aprotinin and erythropoietin. These modalities have made it possible to perform major operations like scoliosis surgery in this group of patients.

Background: More patients are turning to the Internet for health-related information. Studies indicate that this information is being used to make decisions about their management. The aim of this study was to assess the information available specific to scoliosis on the Web using four common search engines.

Methods: Four search engines (Google, Yahoo, Hotmail and Ask Jeeves) were used in scanning the Web for the following key word- “Scoliosis”. Both U.K. only and World Wide sites were accessed. Four Spinal Surgery Consultants independently graded each site for layout, content, relevance to patients as opposed to medical professionals, ease of use and links to other sites. Each point was marked on a scale of 0–2 and a total of 10 points available. Web sites were assessed via U.K. search engines and forty via World Wide search engines. Good was awarded to a site with a score of 7–10; an average awarded for a score of 4–7 and poor was given to a site with a score of 0–4.

Results: For the U.K. search engines, twenty sites were evaluated and five common sites identified (spineuniverse.com, S.A.U.K.org, orthoteers.co.uk, B.O.A.ac. uk and scoilosis.info). From these sites only two were given a rating of good. For the World Wide Web search engines eighteen sites evaluated and seven common sites identified (SRS, spineuniverse.com, scoliosis.org, orthinfo.aaos.org, iscoliosis.com, scoliosisrx.com and scoliosis-world.com). From these sites four were given a rating of good. It was evident that the Scoliosis Association of United Kingdom did not appear in three of the search engines but only in Hotmail.

Conclusion: These results suggest that there are good sites available for patients to access information with regards to their condition and treatment options but there are also very poor sites available where incorrect information is available. Commonly, unfamiliar users of the Web will not search U.K. sites specifically and could easily miss the S.A.U.K. site, which is an excellent site and was one of the two sites via the U.K. search engine awarded a good score. Obviously, there were more good sites via the World Wide Web due to the American healthcare system. We recommend that leaflets should be available to parents and patients with scoliosis with information from the BSS of the condition and available Web sites with good ratings. Also we recommend that these sites be linked to the Royal College of General Practitioners Web site to provide reference on good practice.

Background: Campbell et al from Texas have pioneered the use of Vertical Expandable Prosthetic Titanium Rib (VEPTR) in congenital scoliosis. Our centre is the first in the UK to use it and we report our experience of 5 cases done in the past 2 years. VEPTR works on the principle of expansion thoracoplasty and thoracic spinal growth of upto 0.8 cms/year has been reported by the developers of this device.

Methods: This case series includes one child who had the index surgery in America and is undergoing sequential expansion in Cardiff. All surgeries were done using a standard technique with monitoring of somatosensory evoked potentials. After appropriate soft tissue and bony releases, VEPTR was inserted and expanded by 0.5 cms to maintain tissue tension. Subsequent expansions were done as day case surgeries at 4–6 month intervals through a small incision over the VEPTR. We assessed clinical and radiographic assessment, which included – hemithorax height ratio, Cobb angle, interpedicular line ratio, space available for the lung.

Results: There were 3 males and 2 females with mean age of 6.3 years (range 0.9 to 9 years) at the time of index operation. Average follow up is 2 years (0.4 to 5 years). Average hospital stay for the index surgery was 5 days (4–7 days). All patients had mean of 3 expansions (range: 0–6). Mean improvement in the Cobb angle was seen from 48° to 36° at last followup. Space available for lung improved from a mean of 72 % to 86 %. Mean improvement in hemithorax height ratio was from 72.5% to 86%. One child had mild pain due to prominent metalwork; 2 children had transient brachial plexus neurapraxia, one of whom had progression of a secondary cervical curve and is awaiting further surgery for the same.

Conclusion: Our early results show good improvement of clinical and radiographic parameters. Transient nerve palsies have been well reported on the concave side and occur due to traction on the nerves as a result of increased height of the thoracic cage. This occurred in one initial case and has not been seen later. These results are encouraging but do indicate a learning curve.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging.

Purpose The aim of this study is to find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who were diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level while it was in two patients in Group II (L4/5 or L5/S1). Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score(p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. There is no significant difference in the duration of the procedure as well between the two techniques. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

Background: There has been an exponential rise in Internet use over recent years with over 11 million homes in the United Kingdom currently having access to the Internet. Previous studies have shown that up to 50% of orthopaedic outpatients have researched their condition on the Internet and that this percentage is dependent upon the condition from which they are suffering. The aim of our study was therefore to assess the prevalence of Internet usage among three groups of orthopaedic outpatients and to further determine how the patients felt their Internet research compared to the information received at consultation.

Methods: Data was collected from 150 patients / parents attending three outpatient clinics; 50 consecutive patients attending scoliosis clinic; 50 patients attending paediatric orthopaedic clinic; 50 patients attending back pain clinic.

Results: 58% of scoliosis, 22% of general paediatric and 30% of back pain patients had researched their condition on the Internet. 83% of scoliosis, 64% of paediatric and 80% of back pain patients found this information useful. Nearly all patients, however, would trust their doctor more than the Internet.

Conclusion: We believe therefore that clinicians need to keep up to date with information available on the Inter-net and provide recommended websites to patients wishing to consolidate their knowledge of their condition.

Background: Long waiting lists in the NHS are a cause for public concern especially with regards to progressive conditions like scoliosis. We reviewed records to 61 patients to ascertain whether waiting time had any detrimental influence on their surgical management.

Methods: Retrospective review. Assessment of clinical records and radiographs of 61 patients who had scoliosis surgery over past two years was done by two independent investigators. Patient demographics, waiting times between referral and outpatient review and waiting time for surgery were collected.

Results: There were 41 females and 20 males with mean age of 11.8 years (range, 1– 22 years). Thirty-four patients had thoracic curves (28- right sided), 21 had thoracolumbar curves (19- right sided) and 6 patients had right sided lumbar curves. Mean Cobb angle at presentation was 58° (range,17°–90°) which increased to 71°(range, 30°–120°) at surgery. Average waiting time to be seen in the clinic was 16 months. Average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients (20%), of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° (range, 45°– 80°), which increased to a mean of 59° at surgery (range, 50°–92°). At presentation their Risser grades were: 5 – grade 0, 3- grade 2, 2- grade 4. These 10 patients had waited averagely 7.8 months to be seen in the clinic and for 11 months to have the surgery.

Conclusion: Significant curve progression occurred in 20 % of patients waiting to have scoliosis surgery. Ten of those required much more extensive surgery than originally planned. Long waiting times therefore have a detrimental effect on the surgical management of scoliosis patients.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging. The entry point and the direction of the needle entering into the facet joint are different in these techniques. Further the difficulties encountered in both the techniques are different.

Purpose To find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who was diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level (L4/5 or L5/S1) while it was in two patients in Group II. Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score (p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The severity was graded into none, mild, moderate and severe, depending on the cortical thickness, trabecular pattern, and the size of holes (absence of trabeculae) using sagittal, coronal and transverse sections of CT scan pictures. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearsons Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (Chi-square value = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

Study Design: Retrospective Series.

Objectives: To analyse loss of correction of the anterior wedge angle and the components responsible for the recurrence of kyphosis after surgical stabilisation of dorsolumbar fractures, and to assess the return of functional capacity in these patients.

Materials and Methods: Between January 1998 and March 2003, 34 patients had posterior stabilisation performed with the Universal Spine System (Synthes) for dorsolumbar fracture at a single level with no neurological deficit. There were 26 AO Type A fractures, 5 Type B fractures, and 3 Type C fractures. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The anterior wedge angle, the heights of the discs above and below the fractured vertebra, and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle and posterior). The values were normalised to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up were computed. Short Form 36 (SF-36) was used to assess the functional outcome in each.

Results: The mean follow-up period was 23.6 months (9 to 48 months). The mean anterior wedge angle was 10.1 ± 7.2 degrees in the immediate postoperative period and 17.1 ± 10.9 degrees at latest follow-up (p< 0.001). The mean loss of correction was 7.0 ± 8.5 degrees (−11 to 24) and this showed a linear relationship to the preoperative anterior wedge angle. Furthermore there was a linear increase in the loss of correction of the angle as the follow-up period increased. The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the anterior wedge angle showed significant correlation to the decrease in the anterior segment height at the fractured vertebral body level (Pearson’s coefficient r=0.53 significant at 0.01 level, p=0.001). The mean physical function score from SF-36 was 56.3 and the mean bodily pain score was 49.7. There was no relationship to the angle of kyphosis at follow-up to the physical function score (r=0.12, p=0.50) and the bodily pain score (r=0.14, p=0.44).

Conclusions: There is a progressive loss of correction (increasing kyphosis) after posterior stabilisation with instrumentation that roughly approximates the initial decrease in anterior height of the fractured vertebral body. The degree of loss of correction does not depend on the type of fracture. The loss of correction is related to the preoperative angle of kyphosis.

Study Design: Retrospective review.

Objectives: Rugby union has recently become a highly-paid professional sport. Players requiring anterior cervical discectomy wish to know the effect this will have on their career. To answer this question, the result of the above procedure in professional rugby players was studied.

Methods: A retrospective notes review and telephone interview were conducted on 19 professional rugby players who had a cervical discectomy between 1998 and 2003. Pre and post operative symptoms and numbers returning to rugby after surgery were assessed.

Results: Neck pain was eradicated in eight (42%) of the players, nine (47%) achieved partial relief and two were not helped. Brachalgia was eradicated in fifteen (79%) individuals, improved in two (10.5%) and two (10.5%) had no relief. Fourteen (74%) returned to rugby union, the majority at six months post operatively (range – five to 17 months). Thirteen (68.5%) returned to their pre-operative level of rugby; one dropped to a lesser division and five have never played rugby again (three due to physical inability, one due to club reluctance to insure and one because of a separate injury). Two of the players that returned to rugby have subsequently retired because of neck symptoms. They played three and two years post-operatively at first-class level.

Conclusion: Return to rugby union after anterior cervical discectomy is both likely and safe and therefore need not be a career ending procedure.

Objective: Surgical correction of scoliosis in small stature children is challenging due to the profile of the posterior instrumentation traditionally available. Concerns are also raised with the use of 5 mm rods for posterior correction. The Paediatric USS is a small stature System.

We studied the correction achieved and the maintenance of the correction at a minimum 15 months follow up using the Paediatric USS.

Design: 20 patients with a minimum 15 months follow up were included in the study. Measurements were made for the initial correction of the Cobb angle to assess correction. At 15 months follow up the cobb angle was measured to assess maintenance of correction.

Results: The average age of the patients was 12 ½ years. The average weight was 32 kgs. The commonest etiology was paralytic(40%) followed by congenital (30%), idiopathic (25%) and collagen disorder (5%). King type II (45%) and type IV (35%) were the commonest type of curves. Combined anterior release and posterior stabilization and fusion was the commonest procedure performed. The average pre op Cobb angle was 77.7°, which corrected to 37.6° i.e. 49%. There was no significant loss of correction at 15 months follow-up.

Conclusions: Thus the Paediatric USS allows adequate correction of the curve and does maintain the correction achieved at a minimum 15 months follow up

Objectives: Quantitative research methods have highlighted the psychological implications of spinal deformities in adolescence. However these methods are limited in exploring the adolescent’s perception of the illness and the expectations from treatment. Hence we carried out detailed qualitative interviews with these adolescents and where applicable with their families to examine these issues

Design: Individual contact was made with the adolescents attending the spinal deformity clinic in a specialist centre in Cardiff. Following their consent an interview was carried out using a qualitative semistructured format

Subjects: A total of 10 adolescents and their families attending the spinal clinic for treatment were interviewed

Results All the adolescents and their families had sufficient information and fairly good understanding of their condition and of the treatments available. The impact the deformity had on the individual’s life was variable. Social impairment was higher in these individuals and this was reflected in their interaction with their peers. Most of the families desired an expected timetable of treatemnt and sequence of events. They also felt the lack of buddy or self help gropus. It also gave a better understanding into these teenagers perception of their condition and their attitude towards treatment

Conclusions: These issues probably need to be understood while dealing with these individuals and their families and as health professionals we need to be sensitive to these issues.

The purpose of this prospective study is to evaluate the benefits of intra discal electrothermal treatment (IDET) for discogenic back pain.

40 patients with chronic discogenic back pain underwent this therapy. All the patients had a failed trial of conservative treatment. Patients with a positive provocative discogram were selected for IDET. The outcome is assessed using a SF36 questionnaire pre-procedure and then at 3,6,12,18 and 24 months post-operatively.

The mean age group of the patients was 37 years (range 15–58 years). All the patients had a minimum follow up of 18 months. Out of the 40 patients 5(12.5%) had no improvement and had to undergo an interbody fusion within 6 months following IDET and hence were excluded from the study. No patient developed any neurological complications. Of the rest of the 35 patients at a minimum of 18 months follow-up 56 % (p=0.042) patients had improvement in physical function scores and 52% (p=0.034) had improvement in pain scores as per the SF36.

Conclusion: IDET appears to be an effective alternative to control pain in patients who might otherwise be candidates for spinal fusion.

To assess the results of this technique for stabilisation of severe spondylolisthesis, 12 patients with symptomatic severe spondylolisthesis underwent this procedure. The slipped L5 vertebra was stabilized using a hollow medullary screw through the posterior part of the body of S1 into the slipped L5 body, supplemented with pedicle screws into L5 and S1 with posterolateral fusion.

At one year follow-up, all but one patient had improved in leg pain. 2 patients were aware of the prominent pedicle screws. 360° fusion was achieved without any progression of spondylolisthesis. Thus 360° fusion for severe L5-S1 spondylo-listhesis can be achieved effectively using this technique.

Controversy exists as to whether the biomechanical properties of a 360 lumbar fusion are influenced by the order in which the anterior and posterior components of the procedure are performed.

The fusion technique used Magerl screws to effect the posterior fusion and a Syncage implant (Stratec) to effect the anterior component of the fusion.

Isolated motion segments from calf spines were tested in each of two groups of five. In the first group the posterior fusion was performed first and in the second group the anterior fusion was performed first. Loads were applied as a dead weight of 2Nm in each range of movement of the spine (flexion/extension, lateral flexion and rotation). The range of movement was measured using the Qualisys motion analysis software linked to a set of five cameras, using external marker clusters attached to the vertebral bodies. Each motion segment was tested prior to instrumentation, post anterior or posterior instrumentation and with both anterior and posterior instrumentation.

Ranges of movement following 360 instrumentation were increased in all planes tested when posterior fixation was performed first; flexion/extension 26% v 55% (p=0.020), lateral flexion 18% v 34% (p=0.382), and rotation 18% v 73% (p=0.034).

It was concluded that posterior fixation should not be performed prior to anterior fixation as this results in a significant loss of stability in both flexion/extension and rotation

Aim: To determine the histological changes in discs retrieved at the time of fusion following failed Intra-Discal Electrothermal Therapy (IDET).

Method: Three patients who had failed IDET treatment underwent lumbar interbody fusion. At the time of the operation the disc material and the endplate were sent for histopathology. The histological changes were compared to a degenerate disc and endplate. The staining techniques used were Haematoxylin Eosin stain, Elastic Van Geison and Alcian stains.

Results: In the post IDET specimens there was stromal disorganisation, paucity of chondrocytes and chondrocyte degeneration. These changes were seen in the nucleus pulposus, annulus fibrosis and the endplate as well. Comparatively cadaveric studies using intra-discal radiofrequency thermocoagulation showed histological change only in the nucleus pulposus.

Conclusion: The endplate changes at the cellular level can be widespread following IDET therapy, which can potentially cause alteration of its mechanical properties.

Objective: Controversy exists as to whether the biomechanical properties of a 360° lumbar fusion are influenced by the order in which the anterior and posterior components of the procedure are performed.

Methods: The fusion technique used Mager screws to effect the posterior fusion and a Syncage implant (Stratec) to effect the anterior component of the fusion. Isolated motion segments from five calf spines were tested in each of two groups. In the first group the posterior fusion was performed first and in the second group the anterior fusion was performed first. Loads were applied as a dead weight of 2Nm in each range of movement of the spine (flexion/extension, lateral flexion and rotation). The range of movement was measured using the Qualisys motion analysis system, using external marker clusters attached to the vertebral bodies. Each motion segment was tested prior to instrumentation, post anterior or posterior instrumentation and with both anterior and posterior instrumentation.

Results: Ranges of movement following 360° instrumentation were decreased in all planes. When posterior fixation was performed first; flexion/extension reduced to 55% compared to 26% with anterior fixation first (p=0.020), in lateral flexion 34% v 18% (p=0.382), and in rotation 73% v 18%(p=0.034).

Conclusions: The 360° fusion construct has reduced range of movement if the anterior first approach is used as compared to posterior first approach. Posterior fixation should not be performed prior to anterior fixation as this results in a significant loss of stability in both flexion/extension and rotation.

Purpose: To assess the results of this technique for stabilisation of severe spondylolisthesis.

Method: Twelve patients with symptomatic severe spondylolisthesis were treated with this technique. All the patients had significant symptoms, inspite of conservative measures. The mean duration of symptoms was 3.5 years. The fixation technique was purely done through a posterior approach, with extensive posterior decompression. Stabilisation of the slipped L₅ vertebra was achieved with a trans sacral screw. The point of entry of the screw being the posterior part of the body of S₁ and it traverses the L₅-S₁ disc space into the L₅ body. A hollow medullary screw passed over a guide wire helps achieve the fixation. This fixation is supplemented with pedicle screws into L₅ and S₁ and posterolateral bone grafting. Thus an anterior and posterior fusion was achieved and the severe slip fixed in-situ.

Results: The mean follow-up was 1 year. All but one (8%) patient had improvement in leg pain. 2(16%) patients were aware of the prominent metalwork (pedicle screws). Good 360° fusion was achieved using this technique in all the patients. There was no progression of spondylolisthesis.

Conclusion: Thus, anterior and posterior in-situ fusion for severe L₅-S₁ spondylolisthesis can be achieved effectively using a single incision via a transsacral approach.

Purpose: The purpose of this prospective study is to evaluate the benefits of this treatment for discogenic back pain.

Method: Thirty-four patients with chronic discogenic back pain underwent this therapy. All the patients had a failed trial of conservative treatment. Patients with a positive provocative discogram were selected for intra-discal electrothermal therapy (IDET). The outcome is assessed using a SF 36 questionnaire filled in pre-procedure and then at three, six, twelve and eighteen months and two years post-operatively.

Results: The mean age group of the patients was 37 years (range 15–58 years). All the patients had a minimum follow up of 12 months (range 6–2 years). Out of the 34 patients 5(14%) had no improvement and had to undergo an interbody fusion following IDET. No patient developed any neurological complications. At a minimum of one year follow-up 56% patients had improvement in physical function scores and 52% had improvement in pain scores as per the SF 36.

Conclusion: Thus IDET appears to be an effective procedure in the short-term relief of discogenic back pain in patients who otherwise might be candidates for fusion.