Aims. Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted. Methods. As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients. Results. Of the 90 patients screened, 77 passed the initial screening criteria. A total of 27 patients had a PI-LL mismatch and 23 had a dynamic spondylolisthesis. Following secondary inclusion and exclusion criteria, 31 patients were eligible for the study. Six patients were randomized and one underwent surgery during the study period. Given the low number of patients recruited and randomized, it was not possible to assess completion rates, quality of life, imaging, or health economic outcomes as intended. Conclusion. This study provides a unique insight into the prevalence of dynamic spondylolisthesis and PI-LL mismatch in patients with symptomatic spinal stenosis, and demonstrates that there is a need for a definitive RCT which stratifies for these groups in order to inform surgical decision-making. Nonetheless a definitive study would need further refinement in design and implementation in order to be feasible. Cite this article: Bone Jt Open 2023;4(8):573–579

Aims. Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre. Methods. A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes. Results. All patients had comorbidities and/or non-spinal procedures within the previous year. Most infections affected lumbar segments (20/32), with Escherichia coli the commonest organism (17/32). Causative organisms were identified by blood culture (23/32), biopsy/aspiration (7/32), or intraoperative samples (2/32). There were 56 different antibiotic regimes, with oral (PO) ciprofloxacin being the most prevalent (13/56; 17.6%). Multilevel, contiguous infections were common (8/32; 25%), usually resulting in bone destruction and collapse. Epidural collections were seen in 13/32 (40.6%). In total, five patients required surgery, three for neurological deterioration. Overall, 24 patients improved or recovered with a mean halving of CRP at 8.5 days (SD 6). At the time of review (two to six years post-diagnosis), 16 patients (50%) were deceased. Conclusion. This is the largest published cohort of gram-negative spinal infections. In older patients with comorbidities and/or previous interventions in the last year, a high level of suspicion must be given to gram-negative infection with blood cultures and biopsy essential. Early organism identification permits targeted treatment and good initial clinical outcomes; however, mortality is 50% in this cohort at a mean of 4.2 years (2 to 6) after diagnosis. Cite this article: Bone Jt Open 2024;5(5):435–443

Despite advances in treating acute spinal cord injury (SCI), measures to mitigate permanent neurological deficits in affected patients are limited. Augmentation of mean arterial blood pressure (MAP) to promote blood flow and oxygen delivery to the injured cord is one of the only currently available treatment options to potentially improve neurological outcomes after acute spinal cord injury (SCI). However, to optimize such hemodynamic management, clinicians require a method to measure and monitor the physiological effects of these MAP alterations within the injured cord in real-time. To address this unmet clinical need, we developed a series of miniaturized optical sensors and a monitoring system based on multi-wavelength near-infrared spectroscopy (MW-NIRS) technique for direct transdural measurement and continuous monitoring of spinal cord hemodynamics and oxygenation in real-time. We conducted a feasibility study in a porcine model of acute SCI. We also completed two separate animal studies to examine the function of the sensor and validity of collected data in an acute experiment and a seven-day post-injury survival experiment. In our first animal experiment, nine Yorkshire pigs underwent a weight-drop T10 vertebral level contusion-compression injury and received episodes of ventilatory hypoxia and alterations in MAP. Spinal cord hemodynamics and oxygenation were monitored throughout by a transdural NIRS sensor prototype, as well as an invasive intraparenchymal (IP) sensor as a comparison. In a second experiment, we studied six Yucatan miniature pigs that underwent a T10 injury. Spinal cord oxygenation and hemodynamics parameters were continuously monitored by an improved NIRS sensor over a long period. Episodes of MAP alteration and hypoxia were performed acutely after injury and at two- and seven-days post-injury to simulate the types of hemodynamic changes patients experience after an acute SCI. All NIRS data were collected in real-time, recorded and analyzed in comparison with IP measures. Noninvasive NIRS parameters of tissue oxygenation were highly correlated with invasive IP measures of tissue oxygenation in both studies. In particular, during periods of hypoxia and MAP alterations, changes of NIRS-derived spinal cord tissue oxygenation percentage were significant and corresponded well with the changes in spinal cord oxygen partial pressures measured by the IP sensors (p < 0.05). Our studies indicate that a novel optical biosensor developed by our team can monitor real-time changes in spinal cord hemodynamics and oxygenation over the first seven days post-injury and can detect local tissue changes that are reflective of systemic hemodynamic changes. Our implantable spinal cord NIRS sensor is intended to help clinicians by providing real-time information about the effects of hemodynamic management on the injured spinal cord. Hence, our novel NIRS system has the near-term potential to impact clinical care and improve neurologic outcomes in acute SCI. To translate our studies from bench to bedside, we have developed an advanced clinical NIRS sensor that is ready to be implanted in the first cohort of acute SCI patients in 2022

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Aims. The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs. Methods. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. Results. This investigation included 739,474 spinal surgeries and 739,215 hospitalizations in Japan. There was an average annual increase of 4.6% in the number of spinal surgeries. Scheduled hospitalizations increased by 3.7% per year while unscheduled hospitalizations increased by 11.8% per year. In-hours surgeries increased by 4.5% per year while after-hours surgeries increased by 9.9% per year. Complication rates and costs increased for both after-hours surgery and unscheduled hospitalizations, in comparison to their respective counterparts of in-hours surgery and scheduled hospitalizations. Conclusion. This study provides important insights for those interested in improving spine care in an ageing society. The swift surge in after-hours spinal surgeries and unscheduled hospitalizations highlights that the medical needs of an increasing number of patients due to an ageing society are outpacing the capacity of existing medical resources. Cite this article: Bone Jt Open 2024;5(8):662–670

Aims. Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM. Methods. This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery. Results. A total of 2,114 individuals aged 64.6 years (SD 11.9) who underwent surgery from March 2009 to December 2016 were studied. The most optimal cut-off canal diameters for DcSS are: C3 < 12.9 mm, C4 < 11.8 mm, C5 < 11.9 mm, C6 < 12.3 mm, and C7 < 13.3 mm. Overall, 13.0% (262 of 2,019) of the population-based cohort had multilevel DcSS. Multilevel DcSS (odds ratio (OR) 6.12 (95% CI 3.97 to 9.42); p < 0.001) and male sex (OR 4.06 (95% CI 2.55 to 6.45); p < 0.001) were predictors of developing DCM. Conclusion. This is the first MRI-based study for defining DcSS with multilevel canal narrowing. Level-specific cut-off canal diameters for DcSS can be used for early identification of individuals at risk of developing DCM. Individuals with DcSS at ≥ three levels and male sex are recommended for close monitoring or early intervention to avoid traumatic spinal cord injuries from stenosis. Cite this article: Bone Joint J 2024;106-B(11):1333–1341

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents. Cite this article: Bone Joint J 2023;105-B(4):347–355

Aims. Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS. Methods. A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis. Results. Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC. Conclusion. Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients. Cite this article: Bone Jt Open 2024;5(4):350–360

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review

Adverse events (AEs) are still a major problem in spinal surgery, despite advances in surgical techniques, innovative technologies available and the introduction of checklist and predictive score systems aimed at reducing surgical complications. We previously analysed the results of the introduction of the WHO Safety Surgical Checklist (SSC) in our Institution, comparing the incidence of complications between two periods: from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist effectiveness. The sample size was 917 patients with an average of 30 months of follow-up. Complications were observed in 107 patients (11.6%) among 917 spinal surgery procedures performed, with 159 (17.3%) complications in total. The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. We observed a reduction of the overall incidence of complications following the introduction of the WHO Surgical Checklist: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%) (p<0.0005). Thus, the SSC appeared to be an effective tool to reduce complications in spinal surgery and we proposed to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications. We also believe that a correct capture and classification of complications is fundamental to generate a clinical decision support system aimed at improving patients’ safety in spinal surgery. In the period between January 2017 and January 2018 we prospectively recorded the adverse events and complications of patients undergoing spinal surgery in our department, without using any collection system. Then we retrospectively recorded the intraoperative and postoperative adverse events of surgically treated patients during the same one-year period, using the SAVES v2 system introduced by Rampersaud and collaborators (Rampersaud YR et al. J Neurosurg Spine 2016 Aug; 25 (2): 256-63) to classify them. In the one-year period from January 2017 to January 2018 a total of 336 patients underwent spinal surgery: 223 for degenerative conditions and 113 for spinal tumors. Comorbidities were collected (Charlson Comorbidity Index [CCI]). Overall, a higher number of adverse events (AEs) was recorded using SAVES compared to the prospective recording without the use of any capture system and the increased number was statistically significant for early postoperative AEs (138/336 vs 44/336, p<0.001). 210 adverse events were retrospectively recorded using the SAVES system (30 intraoperative adverse events, 138 early postoperative and 42 late postoperative adverse events). 99 patients (29.5%) on the cohort had at least one complication. Furthermore, the correlation between some risk factors and the onset of complications or the prolonged length of stay was statistically analyzed. The risk factors taken into account were: age, presence of comorbidities (CCI), ASA score, previous surgery at the same level, type of intervention, location of the disease, duration of the surgery. In particular, the duration of the surgery (more than 3 hours) and the presence of previous surgeries resulted to be risk factors for complications in multivariate analyses

When a suspicious spine lesion is identified, an accurate diagnosis based on tissue biopsy is needed to direct towards the correct treatment protocol. Several studies concluded that the percutaneous fluoroscopy guided biopsy of vertebral lesions is a safe, effective and accurate diagnostic tool and is preferred over open techniques when possible. The aim of this study was to review percutaneous fluoroscopy guided transpedicular spinal biopsies at a tertiary hospital over a 6-year period. The research design was a retrospective review of patients who underwent percutaneous transpedicular spinal biopsies under fluoroscopy guidance at a tertiary hospital over a six year period (1st January 2016 to the 31st December 2021). The spine theatre registry and hospital records system were used as the source for data collection. Statistical analysis was conducted to determine the effectiveness of transpedicular spinal biopsies, compare spinal pathology amongst age and gender and to identify any complications. The study analysed 180 biopsies, 120 yielding a positive result (66.67%). Of these 8.9% were pyogenic infection, 18.4% neoplasm, 36.7% Tuberculosis and 2.7% other. There were 75 males and 105 females with an age range between 9 and 86 years and mean age of 43.44. Comparing age and gender found no statistical significance (p = 0.778). Comparing biopsy result and gender showed no statistical significant relationship (p = 0.970). Comparison of biopsy result with age showed no statistical significant association (p = 0,545). Four complications were identified (2.22%). The study showed that fluoroscopy guided percutaneous transpedicular biopsy is an effective and safe modality in obtaining spinal specimens in all age groups for a wide spectrum of spinal pathological lesions

Aims. Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty. Methods. We prospectively analyzed 241 patients with spinal metastasis who underwent palliative surgery from June 2015 to December 2021. Postoperative complications were assessed by the Clavien-Dindo classification; scores of ≥ Grade II were defined as complications. Data were collected regarding demographics (age, sex, BMI, and primary cancer) and preoperative clinical factors (new Katagiri score, Frankel grade, performance status, radiotherapy, chemotherapy, spinal instability neoplastic score, modified Frailty Index-11 (mFI), diabetes, and serum albumin levels). Univariate and multivariate analyses were developed to identify risk factors for postoperative complications (p < 0.05). Results. Overall, 57 postoperative complications occurred in 47 of 241 (19.5%) patients. The most common complications were wound infection/dehiscence, urinary tract infection, and pneumonia. Univariate analysis identified preoperative radiotherapy (p = 0.028), mFI (p < 0.001), blood loss ≥ 500 ml (p = 0.016), and preoperative molecular targeted drugs (p = 0.030) as potential risk factors. From the receiver operating characteristic curve, the clinically optimal cut-off value of mFI was 0.27 (sensitivity, 46.8%; specificity, 79.9%). Multivariate analysis identified mFI ≥ 0.27 (odds ratio (OR) 2.94 (95% CI 1.44 to 5.98); p = 0.003) and preoperative radiotherapy (OR 2.11 (95% CI 1.00 to 4.46); p = 0.049) as significant risk factors. In particular, urinary tract infection (p = 0.012) and pneumonia (p = 0.037) were associated with mFI ≥ 0.27. Furthermore, the severity of postoperative complications was positively correlated with mFI (p < 0.001). Conclusion. The mFI is a useful tool to predict the incidence and the severity of postoperative complications in spinal metastases surgery. Cite this article: Bone Joint J 2024;106-B(12):1469–1476

Background. Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques. Methods. PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios. Results. Differences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented. Conclusion. The study is due to open in May 2024 and complete in 2026. Conflicts of Interest. No conflicts of interest declared. Sources of Funding. NIHR Health Technology Award – grant number NIHR153170. Trial presentations so far. APOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024

Abstract. Objectives. Spinal stiffness and flexibility terms are typically evaluated from linear regression of experimental data and are then assembled into 36-element matrices. Summarising in vitro test results in this manner is quick, computationally cheap and has the distinct advantage of outputting simple characteristic values which make it easy to compare results. However, this method disregards many important experimental features such as stiffening effects, neutral and elastic zones magnitudes, extent of asymmetry and energy dissipation (hysteresis). Alternatives to the linear least squares method include polynomials, separation of the load-displacement behaviour into the neutral and elastic zones using various deterministic methods and variations on the double sigmoid and Boltzmann curve fits. While all these methods have their advantages, none provide a comprehensive and complete characterisation of the load-displacement behaviour of spine specimens. In 1991, Panjabi demonstrated that the flexion-extension and mediolateral bending behaviour of functional spinal units could be approximated using the viscoelastic model consisting of a nonlinear spring in series with a linear Kelvin element. Nowadays viscoelastic models are mainly used to describe creep and stress relaxation, rather than for cyclic loading. The aim of this study was to conclusively prove the viscoelastic nature of spinal behaviour subject to cyclic loading. Being able to describe the behaviour of spine specimens using springs and dampers would yield characterising coefficients with recognisable physical meaning, thus providing an advantage over existing techniques. Methods. Six porcine isolated spinal disc specimens (ISDs) were tested under position and load control. Visual inspection of the load-displacement graphs from which the principal terms of the stiffness and flexibility matrices are derived suggest that the load-displacement behaviour could be idealised by a nonlinear spring system with damping. It was hypothesised that the contributions arising from non-linear spring-like behaviour and damping could be separated for each of the principal load-displacement graphs. Results. The principal elements from position and load control tests were plotted with load on the vertical axis and displacement on the horizontal axis, and a polynomial representing spring force was fitted to the data. This polynomial was subtracted from the experimental data. The remainder - representing damping force - was plotted against displacement and velocity and compared to idealised plots for different types of damping behaviour. Applying this reasoning to the six principal load-displacement plots obtained from stiffness and flexibility tests revealed that four of six exhibit behaviour which is a combination of a nonlinear hardening spring and viscous damper. However, for flexion-extension and mediolateral bending, the damping behaviour is more akin to coulomb damping with viscous influences, characterised by a steep central linear region and near horizontal regions at the extremes. These trends were common amongst all six specimens within the study sample size. Conclusions. The unique approach described here has allowed the characterisation of the load-displacement behaviour of ISDs in terms of characteristic mass-spring-damper systems. This is an important development which allows experimental findings to be framed in terms of mechanical contributions to a given load-displacement behaviour. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) present significant challenges for both patients and surgeons. Understanding the specific UROs types is crucial for improving patient outcomes and refining surgical strategies in ASD correction. Method. This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database spanning from 2017 to 2021. Patient information was extracted using specific CPT codes related to posterior pedicle fixation. Result. In a cohort of 1088 patients undergoing posterior spinal deformity corrections, we examined various preoperative factors to discern their correlation with reoperation prevalence. Our analysis revealed no statistically significant differences in reoperation prevalence concerning gender (male: 4.0%, p=0.131) or ethnicity (Hispanic: 4.2%, p=0.192). Similarly, no notable associations were identified for diabetes mellitus, smoking status, dyspnea, history of severe COPD, hypertension, ASA classification, or functional health status before surgery, with reoperation prevalences ranging from 3.2% to 8.8% and p-values spanning from 0.146 to 0.744. Overall, the reoperation prevalence within the entire cohort stood at 5.2% (55 cases). In terms of the types of reoperations investigated, spinal-related procedures emerged as the most prevalent, accounting for 43.7% (24 cases), followed closely by wound site revisions at 23.6% (13 cases). Additionally, gastrointestinal-related procedures and various other miscellaneous interventions, such as uroscopy, demonstrated reoperation prevalences of 7.2% (4 cases) and 25.5% (14 cases), respectively. Conclusion. our findings highlight the diverse spectrum of reoperation procedures encountered following posterior spinal deformity corrections, with wound site revisions and spinal-related interventions being the most prevalent categories. These results emphasize the complexity of managing UROs in spinal surgery and the need for tailored approaches and infection/incision protocols to address the specific challenges associated with each type of reoperation

Abstract. Background. University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Aim. Prospective audit to see how many admissions, correct pathways were followed?. Materials & Methods. Prospective data collection prospective over a period of 3 months: starting from 8.11.2020 to 31.01.2021. Results. Spinal admissions represent around 22% of MTC admissions. The closing loop showed higher amount of admission (45 in comparison with the first audit 28). 42 patients had fractures where three had cord syndromes. 13 patients out of the 45 (29%) were managed operatively. After changing to MTC, more indirect referral from other hospitals representing 64% of total admission with one wrong referral (2.2%) that came to the MTC and could have been managed locally. On the other hand, repatriation rate has improved from 61% to 84%, however, repatriation time was longer than expected with >1 week represents 78%. Conclusions. Changing to MTC had a great impact with increased work load in the trust. Repatriation would be aimed for within 72 hours from treatment either conservative or postoperative. More attention should be paid towards the appropriate referral pathways to avoid wrong referral

Introduction and Objective. Pectus carinatum is a common congenital anterior chest wall deformity, characterized by outward protrusion of sternum and ribcage resulted from rib cartilage overgrowth. The protrusion may be symmetrical or asymmetrical. Pectus carinatum association with mitral valve diseases, Marfan's syndrome, and scoliosis enforces that poor connective tissue development as possible etiological factor. Despite the coexistence of pectus carinatum and scoliosis has attracted the attention of some researchers, the association between pectus carinatum and the other spinal deformities has not been studied comprehensively. The frequency of spinal deformity in patients with pectus carinatum and the mutual relationships of their subtypes are needed to be studied to determine the epidemiological character of the combined deformity and to plan patient evaluation and management. Our study aimed to investigate the association, define the incidence and evaluate the characteristics between different types of spinal deformities and Pectus carinatum. Materials and Methods. Radiological and physical examinations were performed for 117 pectus carinatum patients in Marmara university hospital/Turkey in the years between 2006 and 2013. The incidence of spinal deformity was calculated. Spinal deformities were classified as scoliosis, kyphosis, kyphoscoliosis, and spinal asymmetry, whereas pectus carinatum were subdivided into symmetric and asymmetric subgroups. The relationship between spinal deformities and the symmetrical-asymmetric subtype of pectus excavatum was statistically analyzed, Pearson chi-square test was used to compare the association of qualitative data. The significance level was accepted as p <0.05. Lastly, the angular values of the deformities of scoliosis and kyphosis patients were measured using the Cobb method. In this way, the magnitude of the deformity was given as a numerical value. Results. Spinal deformity was detected in 23 (17 symmetrical PE and 6 asymmetrical PE) of 117 pectus excavatum patients. Scoliosis and kyphosis were seen equally in symmetrical pectus carinatum, whereas scoliosis was seen in 33.3% and kyphosis in 50% in asymmetric pectus carinatum patients, respectively. However, there were no statistically significant differences in the distribution of scoliosis and kyphosis in patients with symmetrical and asymmetrical PE. Idiopathic scoliosis constituted the most common scoliosis group. Congenital kyphosis was not found in any kyphosis patient. The average Cobb angle of scoliosis patients was 32°, and the mean T2-T12 kyphosis angle of these patients was 55.5°, while the average kyphosis angle of those with kyphosis deformity was 71°. Conclusions. Patients with Pectus carinatum have a higher incidence of spinal deformities than the normal population. Such high concomitant incidence should be taken under consideration in evaluating and treating patients presenting with either deformity

Background. NHS improvement advocates same day emergency care (SDEC) for patients requiring additional specialism than can be provided in an Emergency Department. A novel physiotherapist-led spinal SDEC unit was established in January 2020, integrated within the on-call spinal service. The aim of this paper was to evaluate patient and peer satisfaction with the spinal SDEC. Methods. Patient satisfaction questionnaires and/or friends and family tests were collected from patients over a six-month period. Questionnaires evaluated satisfaction with recommendations given, service given, staff friendliness. Anonymous, completed questionnaires were uploaded onto a spreadsheet. Peer satisfaction was assessed using a google sheets document emailed to interface, primary care and community services. The questionnaire captured the respondents’ role, how many patients they had referred to the SDEC, reasons for referral, ease of referral, and compared this new pathway with the previous pathway. All patient's satisfaction responses recommended the service to family and friends (n=110 extremely likely, 8 likely) (6% total seen). All respondents were satisfied with the service they received (n=80 very satisfied, n=12 satisfied) and recommendations made (n=86 very satisfied, n=6 satisfied). Of peer satisfaction, 26 respondents (n=12 (46%) physiotherapists, n=6 (23%) first contact practitioners, n=6 (23%) advanced practice physiotherapists, n=1 (4%) GP, n=1 (4%) nurse) reported the SDEC delivered a better pathway and outcomes (n=25, 96%), and 20 (77%) respondents reported favourable comments of the service and its impact on patients and referrers. Conclusion. Peer and patient satisfaction data support the use of a physiotherapist-led spinal SDEC in emergency and urgent spinal care pathways. Conflicts of interest: No conflicts of Interest. Sources of interest: No sources of funding