Introduction

Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document.

Objective

To investigate, through a randomised, single blind, Quasi-experimental trial, whether immediate physiotherapy after lumbar micro-discectomy enables patients to become independently mobile more rapidly with no increase in risk of complications.

Purpose: To investigate whether patients who present with Lumbar radicular signs and symptoms and who have MRI scans reported as showing no nerve root compression, improve following Nerve Root Injection (NRI).

Methods: The clinic notes and MRI results of 127 patients who underwent NRI under the care of two spinal surgeons were reviewed retrospectively. Those patients with radicular pain and MRI scans reported as showing no nerve root compression were evaluated further. All patients had a selective NRI using a standard image intensifier guided oblique approach with 40 mg Kenalog and 1 ml 0.25% bupivacaine injected around the nerve root. The patients’ symptoms and signs were noted at the follow up appointment six weeks later.

Results: 43 of the 127 patients who underwent selective NRI had MRI scan reports suggesting no nerve root compression. Of the 47 patients 30 (69%) reported a significant improvement (p=0.0009) in their leg pain following the NRI, the remaining 13 patients reported no relief.

Conclusions: Clinicians treating patients presenting with lumbar radicular signs and symptoms should not rely on MRI report alone in the diagnosis and management of the patient. The results show that patients who exhibit lumbar radicular signs and symptoms who have non-concordant MRI results may still benefit from treatment (NRI).

Ethics approval: None required

Statement of interest: None

Aims: To establish whether self rated disability and physical function in people with Chronic Low Back Pain (CLBP) are correlated.

Design/Methods: The study was observational/correlational in design. One hundred patients attending orthopaedic surgical clinics or for physiotherapy at the Northern General Hospital (NGH) site of Sheffield Teaching Hospitals (STH) were recruited for the study. Once consent was obtained patients were asked to complete the Oswestry Disability Index (ODI) and undertake the Harding battery of physical performance.

Results: The Pearson product moment correlation coefficients were calculated for the group using SPSS v.13. The results show low negative correlations for the whole group with low to moderate negative correlations for the male group. There were no statistically significant correlations for the physical performance measures and ODI in the female sub-group.

Pearson correlation Co-efficient results for all participant

Conclusions: The lack of correlation between self-rated disability and physical performance suggests that the two constructs are un-related and as such should be measured separately. There were significant differences between the physical performance parameters between genders. This enhances the findings of previous studies which, together with this study suggest that the level of physical performance should not be extrapolated from self-rated disability questionnaires.

Ethics Approval: The study was approved by the North Sheffield ethics committee (ref: 07/H1308/120) and Sheffield Teaching Hospitals NHS Foundation Trust (ref: STH 14280)

Statement of interest: None

Purpose of study: There is a controversy in the surgical treatment of unstable thoracolumbar burst fractures scoring high on the Load Sharing Classification (LSC). We have been treating unstable thoracolumbar fractures with postero-lateral fusion using short segment instrumentation and in this study we investigated our complication rate.

Methods and results: We retrospectively reviewed notes and radiographs of patients presenting with thoracolumbar burst fractures and stabilised with a short-segment instrumented postero-lateral fusion between 1998 and 2007. We identified 31 patients who had adequate documentation and radiographs. Twenty patients had a high (> =7) LSC score and none of these fixations failed. Overall early and late complication rate was low (one wound infection, one dehiscence and four unrelated infections), the one metalwork failure related to infection. Fifty-five percent of patients returned to full-time work. Approximately 50% of correction of kyphosis was lost but the average kyphosis at final follow-up was 11 degrees that we thought was acceptable.

Conclusion: We concluded that treating unstable burst fractures with posterior instrumented fusion alone using a pedicle screw construct does not result in late instrumentation failure, high complication rate or unacceptable final deformity.

Ethics approval: None

Interest Statement: None

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: Metastatic spinal disease continues to be a challenge in the management of patients with advanced malignancy. Anterior en bloc spondylectomy and stabilisation, a more extensive procedure, is favoured as it is thought to provide a curative resection and improve the overall outcome (Tomita et al,2002; Wiegel, 1999).

Aim: The aim of this study was to see if there is still a role for extensive posterior decompression (Wide laminectomy and transpedicular decompression) with stabilisation in the treatment of these patients which is the mode of treatment used in our institution and favoured by some others (Bauer, 1997)

Patients and Methods: We retrospectively reviewed a cohort of patients treated in our institute by extensive posterior decompression and stabilisation between 2000 to 2006. We excluded patients having haematological primaries and anterior surgery and those with inadequate data.

Outcome measures used were post operative mortality, Post operative improvement in Frankel score, level of pain perception, level of mobility and ability to perform activities of daily living.

Results: 52 patients had posterior surgery with Colarado instrumentation being used in a majority. There was a slight male preponderance with an average age of 67 years. The mean length of follow up was 12 months.57% patients were dead at last review. 52 % patients showed an improvement in Frankel scores. There was a significant decrease in analgesic requirement post operatively with an improvement in pain scores. Similarly there was an improvement in the ability to perform activities of daily living and the level of mobility. No major surgical complications were noted bar a few superficial wound infections. Revision surgery was done in 6 cases. In 2 it was for a tumour recurrence, for broken rods in 2 and converted to anterior in 2. There were 4 immediate peri operative deaths.

Conclusion: Our results are comparable to Bauer et al, 1997 and other series. Posterior spinal surgery is very much a viable treatment option to treat selected cases with metastatic spinal disease. It avoids all the complications and morbidity of anterior surgery while producing an overall improvement in pain, the quality of life, level of mobility and neurological status.

Study Design. Randomized, single blind, Quasi-experimental trial.

Objective. To investigate whether immediate physiotherapy post lumbar micro-discectomy enables patients to become independently mobile more rapidly with no increase in risk of complications

Summary of Background Data. Although studies have demonstrated the efficacy of rehabilitation post lumbar discectomy, none have looked at physiotherapy commencing immediately post operatively.

Methods. A total of thirty patients were randomized to an immediate group commencing physiotherapy within two hours post-operatively or a control group receiving physiotherapy first day post-operatively. Outcome measures included the time taken for the patient to become independently mobile post-surgery, Oswestry Disability Index and pain scores (VAS and short form McGill) collected pre-operatively, post-operatively at four weeks, and three months.

Results. The results indicated significantly reduced time to independent mobility (p=0.009) and return to work (p=0.002) in the immediate group. There was no significant difference in disability and pain scores at four weeks and three months between the groups. Early mobilisation did not result in increased complications.

Conclusions. Immediate physiotherapy following first time single level lumbar micro-discectomy enables patients to become independently mobile more rapidly and return to work sooner. Immediate physiotherapy may enable patients to experience earlier discharge with associated cost benefits to healthcare.

Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved.

The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.

Background: It is generally accepted that surgical correction in adolescent idiopathic scoliosis (AIS) is largely for cosmesis. Scoliometer measurements of back surface asymmetry and rasterstereographic methods are used to attempt to quantify the surface deformity, These methods are also used to determine the ‘success’ of surgery. This study objectively evaluates trunk cosmesis from pre-operative photographs.

Methods: This is a prospective cohort study. Twelve pre-operative girls with thoracic AIS had standard photographs taken in the standing and forward bending positions. The mean Cobb angle is 74°, mean age 13.7 years. Twenty observers were selected by their profession (3 Spinal Consultants, 4 Orthopaedic Specialist Registrars, 4 nurses, 4 medical illustrators and 5 lay-people). Each patient’s photographs were arranged on a single sheet and the observer was asked to arrange the patients in order of cosmesis and having done this to give a score between 0 (best) and 100 (worst) for overall cosmesis.

Results: There was no good agreement either in the ranking or the scoring for any of the groups of observers. Some observers agreed quite well whilst others ranked and scored much differently to the ‘mean’.

Conclusion: Cosmesis is a spectrum and is most definitely in the eye of the beholder with wide disagreement between individuals both for ranking and scoring cosmesis. We must identify the components of trunk cosmesis (for the majority of observers) so that we can quantify these and produce a score to reflect what we are trying to treat. Only then will we be able to assess the results of our treatments.

Following fixation of proximal femoral fractures in the elderly the operating surgeon may request that the patient be mobilised partially weight bearing on the injured limb. This instruction is most likely if the bone quality is very poor or the fracture pattern unstable, despite evidence that full weight bearing does not affect outcome.

98 elderly patients with proximal femoral fractures treated by either hip screw device, cannulated screws or hemiarthroplasty, who were previously independently mobile, have been followed prospectively to determine their ability to comply with partial weight bearing instructions.

A specially designed capacitance foot pressure device was used to determine percentage body weight transferred through the injured limb on mobilising under physiotherapy instruction over 5 days, and factors thought to be predictive of success in partially weight bearing were measured using simple ward tests.

14 patients failed to mobilise independently prior to discharge from hospital and were excluded from further analysis. Of the remaining 84 patients only 24 (28%) successfully managed to partially weight bear 30-50% of their body weight on the injured limb. Only six of those who were unable to partially weight bear on starting to walk after surgery had learnt to do so by the fifth day. Factors indicating success or failure were mental test score, grip strength and straight leg raise on the unaffected side.

This study has shown that the majority of elderly hip fracture patients are unable to partially weight bear but, if required, success can be predicted by a few simple ward tests.

It is hoped that this information will lead to the more appropriate use of inpatient physiotherapy resources.