Objective: To determine whether extended scope physiotherapists (ESP’s) in spinal clinics are able to accurately assess and diagnose patient pathology as verified by MRI findings.

Methods: This is a prospective study of 318 new spinal outpatients assessed and examined by one of two spinal ESP’s. 76 patients (24%) were referred for an MRI scan. At the time of request for MRI scan the likelihood of specific spinal pathology correlating with the MRI scan was noted on a four point scale dividing the patients into 4 groups:

Group 4 = Very high suspicion of pathology (n=41)

Results: Of the 76 patients referred for an MRI scan, 54 (71%) had an MRI scan result that would correlate with the clinical picture. Looking at the percentage of scans correlating with the clinical picture for each of the 4 groups:

Group 4: 88%

Conclusion: Dividing the patients into groups by clinical suspicion is essential for evaluating a clinician’s ability in spinal assessment. Further evaluation of Consultants, Fellows and Specialist Registrars is on going. This type of study could form a basis for competency measures for staff development and training if they are undertaking extended roles.

Introduction: Blood conservation is important in surgery for adolescent idiopathic scoliosis due to the potential for significant blood loss and need to avoid allogeneic transfusion in young, commonly female, patients. Previous studies have shown that a combination of blood conservation methods may be effective in reducing the need for allogeneic blood transfusion. We have carried out a study to investigate if the sole use of intraoperative red cell salvage in surgery for adolescent idiopathic scoliosis is effective and can lead to a reduced rate of allogeneic transfusion.

Patients and Methods: 56 patients aged between 10 and 17 underwent posterior spinal surgery for correction of idiopathic scoliosis. In 34 patients intraoperative cell salvage was used and salvaged blood re-infused perioperatively. This group was compared with a control group of 22 patients in whom only allogeneic blood transfusion was used. All patients underwent hypotensive anaesthesia. Other forms of blood conservation, such as predonation, were not used. Data was gathered on patient demographics, operative details, quantity of blood reinfused, pre and post operative haemoglobin levels and total allogeneic transfusion requirement. Operative data was gathered prospectively and blood transfusion data provided by the transfusion centre.

Results: In the cell salvage group an average of 309mls of blood was reinfused and these patients were transfused an average of 1.8 units less allogeneic blood in the peri-and post-operative period (p< 0.001). 74% of these patients required no allogeneic blood compared with 27% in the control group. There were no complications related to the use of intraoperative red cell salvage.

Conclusion: Intraoperative red cell salvage is effective in reducing the need for allogeneic transfusion in children undergoing posterior surgery for scoliosis correction.

High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80–95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleeration forces in the order of 15–25G. The rate of application of these forces maybe upto 250G per sceond. Upto 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20–30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent.

A prospective case series, admitted to QMC Nottingham, from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and magnetic resonance Imaging (incorporating T1, T2 weighted and STIR saggital sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots).

In this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery ( indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra.

11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries.

This study confirms a high incidence if spinal fracture and particularly occult spinal injury. Evidently vertical emergency aircraft ejection imposes major insults on the spinal column. Once, appropriately prioritised, life preservation measures have been undertaken, an early MRI of the spne is mandatory as part of comprehensive patient evaluation.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Study design: A retrospective review of patient records with recent clinical and radiographic assessment.

Objective: Long-term evaluation of the Luque trolley for posterior instrumentation in congenital scoliosis.

Summary of background data: From a group of 51 cases treated with the Luque trolley, we review 10 patients with progressive congenital scoliosis (5male, 5female) for a mean follow-up period of 14.8 years, to mean age of 19 years. The mean Cobb angle of the primary curve before surgery was 69.5 degrees. The mean Cobb angle of the secondary cervico-thoracic curve before surgery was 37.1 degrees and of the caudal secondary curve was 26.4 degrees. The mean age at surgery was 5.0 years. 8 patients had a selective epiphysiodesis procedure, 2 with hemi-vertebrectomy, and all underwent single- stage (7 patients) or dual-staged (3 patients) posterior instrumentation with a Luque trolley growing construct.

Method: Clinical evaluation and sequential measurements of Cobb angle were done, with recording of further surgical procedures, associated complications, and final coronal balance. The thoracolumbar longitudinal spinal growth (T1-S1) and growth in the instrumented segmented were also calculated.

Results: The mean preoperative primary curve Cobb angle of 69.5degrees, corrected to a mean postoperative angle of 30.6 degrees, with progression from here to curve magnitude of 38.8 degrees on latest follow up (approximate rate of progression of 0.55 degrees per year).

The mean pre-operative cephalic (cervico-thoracic) Cobb angle of 37.1degrees, corrected to 22 degrees, with progression to 26.6 degrees.

The mean pre-operative caudal (lumbar) Cobb angle of 26.4degrees, corrected to16.2 degrees, this later progressed to 20.6 degrees.

Coronal plane translation measured 1.68 cm at latest follow up [range 0.5–5.1cm].

The thoracolumbar longitudinal growth measured a mean of 8.81cm (approx0.8 cm/year) with a recorded lengthening of 2.54 cm (approx 0.23cm/year) in the instrumented segmented. Half the patients did not require further surgery.

Conclusion: Selective fusion does not always prevent further deformity in congenital scoliosis. The addition of posterior growing construct instrumentation did demonstrate capacity for good correction of primary and secondary curvatures and a limited capacity for further longitudinal growth.

Background: To present the experience of three centres in the surgical management of scoliosis in patients with Prader-Willi syndrome¹, and to describe the associated complications. A retrospective case series reviewing treatment type, surgical outcomes and complications with a review of the literature

Methods: There were 15 patients treated surgically in the three centres over an eleven year period. The average age at initial surgery was 9.6 (5 to 16+8) yrs. Minimum follow-up from index procedure was 28 months. 5 underwent posterior spinal fusion, 2 had anterior fusion alone and 2 had combined anterior/ posterior fusions as their index procedure. 6 patients were initially managed with growing rod constructs. Outcome measures included fusion rate, curve progression and complication rate.

Results: 11 patients achieved a solid fusion. 2 patients were still undergoing the lengthening process and were thus unfused. 1 patient had broken instrumentation with pseudarthrosis, and one patient not fit for final fusion remained without implants. No curve progression was seen in the 11 fused spines. Progressive kyphosis and scoliosis were noted in the two ongoing lengthening patients. There were 17 revision procedures not including planned lengthenings, with a total of 59 surgical procedures. 5 rod breakages occurred in the growing-rod patients. There were 11 infections (4 deep) in 7 patients. There were 6 respiratory complications, 3 requiring ventilatory support. One patient had post-operative neurological deterioration requiring re-exploration and who had grade 3 paraparesis at final follow-up. In total there were 36 complications (240%)

Conclusion: The outcome of surgical management of scoliosis in Prader-Willi syndrome is adversely affected by the obesity and respiratory difficulties of the patients and complications abound². The use of growing constructs, whilst enabling the management of the growing child, greatly increases the risk of implant failures. Their use in Prader-Willi requires careful consideration.

Objective To assess the validity of Somatosensory Evoked Potential (SSEP) monitoring in identifying potential spinal cord vascular damage resulting from segmental artery ligation in anterior spinal deformity correction.

Design SSEP monitoring was undertaken in patients deemed at risk of spinal cord vascular injury during corrective surgery. The segmental vessels of the vertebral bodies to be instrumented were identified. Baseline SSEPs were obtained prior to application of non-crushing microvascular clamps. After ten minutes of occlusion, further SSEP recordings were made. Surgery proceeded with either, vessel ligation and division allowing anterior instrumentation, or vessel sparing anterior release.

Subjects 22 patients were included; 7 had Scheuermann’s hyperkyphosis and 15 had scoliosis (11 idiopathic, 3 syndromic, 1 neuromuscular). Perceived risk was defined by the presence of hyperkyphosis, abnormal neurological examination or radiologically identified spinal cord anomaly.

Outcome Measures A drop of 30% from baseline reading was taken as significant. Post-operative neurological outcome was correlated with intra-operative signal change and alteration in planned surgery.

Results There was no significant drop in post-clamping SSEPs in the hyperkyphotic patients. In 3 scoliosis patients anterior instrumentation was abandoned and a release was performed. Staged posterior instrumentation followed. In a further 2, anterior instrumentation proceeded but in a modified fashion. The remaining 10 patients had no significant drop and underwent the surgery as planned. No patient sustained a neurological injury.

Conclusions SSEP monitoring is safe in assessing the apparent contribution of segmental vessel blood supply to the spinal cord in spinal deformity surgery. It has allowed timely alteration of planned surgical procedures that potentially may have caused vascular spinal cord injury.

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone.

Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply.

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius which has an average ulnar inclination of 22 degrees and an average volar tilt of 14 degrees. These inclination and tilt produce superimposition of images and imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint.

We describe two new radiographic views of the distal radius, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. These are the tangential views of the articular surface of the distal radius taken by elevating the wrist so that the forearm makes an angle to the operating table to negate the effects of natural inclination and tilt in antero-posterior and lateral views. The images were compared with the images of standard antero-posterior and standard lateral views. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them. However, no screw was seen penetrating the joint in these new views.

The tangential views showed correct relation of the screws with the articular surface and a more distal placement of the plate was possible. This enabled the screws to engage the sub-chondral bone and obtain bi-cortical purchase in presence of dorsal comminution. We recommend use of these views in open reduction and internal fixation of distal radius fractures.

Objective: To compare the presentation, diagnosis and treatment of spinal tuberculosis in two cities, one in the UK, and one in Malaysia

Design: Retrospective comparison over a five-year period from June 1995. The Centres studied were the Royal Orthopaedic and Queen Elizabeth Hospitals, Birmingham (UK), and the Kuala Lumpur General Hospital (KL), Malaysia.

Subjects: There were 80 patients (29 females, mean age 42) in the KL group, and 19 patients (8 females, mean age 45) in the UK group.

Outcome measures: Frankel grading before and after treatment were measured for both groups.

Results: KL patients had higher rates of immunocompromise, and had fewer spinal levels involved, 2.1 compared with 2.6 (p-−0.04). There were 65 procedures, 58 positive ZN stains, and 65 positive cultures as compared with 24, 2 and 9 in Birmingham respectively. Improvement in Frankel grading was seen in four patients in UK (5 grades), and in 17 patients in KL (29 grades).

Conclusions: Although the two groups exhibited similar demographics, the rate of immunocompromise-related tuberculosis, severity of neurological deficit, and type of surgery undertaken differed significantly. Reasons for the difficulty in identifying the tubercle bacillus in Birmingham are discussed.