Background

Loss of muscle mass (sarcopenia) and function in ageing are associated with reduced functional ability, quality of life and reduced life expectancy. In cancer patients, age related muscle loss may be exacerbated by cachexia and poor nutritional intake. Individuals with widespread disseminated disease are most prone to increasing functional decline, increased morbidity and accelerated death. However subjective assessments of physical performance have been shown to be poor indicators of life expectancy in these patients.

PURPOSE OF THE STUDY

Occipitocervical fixation and spondylodesis is indicated in various cases of occipitocervical instability. The aim of this retrospective study was to evaluate the results of occipitocervical fixation at our institutions.

Introduction

The main symptoms in multiple myeloma are the result of skeletal destruction mainly the vertebral column. The current treatments for multiple myeloma include radiotherapy and chemotherapy but unfortunately it is still incurable. However, the symptoms and quality of life of these patients can be improved by cement augmentation which has gained popularity in the recent years.

Vertebral compression fractures are very common. 250,000 are diagnosed annually in the United States with 80% due to osteoporosis¹. Symptomatic relief with conservative therapy is often difficult to achieve. The consequence of significant pain is deterioration in quality of life and often in level of function. They independently increase mortality rate¹.

Balloon kyphoplasty is a relatively new technique which stabilises the vertebral body and restores saggital spinal alignment. Excellent pain relief and improved functional outcome is reported^2,3. We aim to confirm this.

All patients receiving balloon kyphoplasty treatment at Derby Hospitals NHS Trust from April 2006 to August 2010 were entered prospectively onto a database. Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) for function were recorded. Technical data including number of levels, cement volume, screening time and kyphosis correction was recorded.

198 patients underwent balloon kyphoplasty between April 2006 and August 2010. Some data was incomplete. 105 patients had sufficient data for meaningful analysis. 170 levels were operated on in 105 patients. 65% (n=68) of patients were female and the average age was 74.

The average pre-operative visual analogue score (VAS) was 8.2. This decreased to 4.0 in the immediate postoperative period. This dramatic improvement remained and was 4.1 at 6 weeks, 3.3 at 6 months and 3.6 at 1 year. The average pre-operative Oswestry disability index (ODI) was 58. This improved to 47 in the immediate post-operative period. At 6 weeks this had improved further to 40 and further improvements were seen at 6 months (ODI 37) and 1 year (ODI 38).

Balloon kyphoplasty should be considered in all patients with ongoing pain following an acute vertebral compression fracture that doesn't respond to conservative treatment.

Clinical and radiological assessment of results of vertebral body stenting procedure.

Introduction: Use of metallic stents along with cement have shown good restoration of the vertebral body in cadaveric spines. We have presented the early results of vertebral body stenting done at Royal Derby Hospitals.

Patients and Methods: All patients had a transpedicular approach to the vertebral body. The vertebral body stent was expanded using a balloon as in balloon kyphoplasty. The balloon was removed leaving the stent in place. The resultant cavity was filled with partially cured polymethyl methacrylate in osteoporotic fractures and calcium phosphate cement in traumatic fractures.

Radiological assessment included pre operative measurement of vertebral body angle, correction achieved and maintenance of correction at follow up

All patients were assessed using the visual analogue score and oswestry disability index.

The procedure was done in 14 fractures (10 patients). 9 fractures were traumatic while 5 were osteoporotic fractures. The mean age of the traumatic fractures was 54.28 years while the mean age of osteoporotic fractures was 82.34 years. Mean follow up was 10 months. All traumatic fractures were type A 3.1. Mean vertebral body angle correction achieved was 8.3° (4° to 14.2°). None of the patients lost the reduction at follow up.

The mean VAS for pain at 6 months was 3.8. The mean oswestry disability index was 22% for traumatic fractures, while it was 44% for osteoporotic fractures.

Vertebral body stenting is a safe procedure. It was successful in restoring the anterior column with encouraging radiological and clinical results.

To assess how effective are the prognostic scores and the role of delayed presentation in predicting the outcomes in patients with metastatic spine disease.

Retrospectively data collected from December 2006 to December 2009. Medical records review included types of tumours, duration of symptoms, duration from referral to definitive treatment, expected survival, functional status before and after treatment. Karnofsky performance score and Modified Tokuhashi were used.

Results: 50 patients underwent surgical stabilisation for metastatic spine disease with or with out cord compression. Age ranged from 39 to 87 years (Avg: 64). Patients had four main types of tumours; (Myeloma 30%, Lymphoma 22% Lung CA 16% and Renal 12 %).

Inpatients without cord compression, the average time from referral to definitive treatment is 17 days. Over all fictional status improved in 70% of cases following surgical intervention. Patients who presented with cord compression had surgery with in 49 hours. Patients with high prognostic scores did not survive as long as expected. On the contrary, patients with poor prognostic scores survived longer than expected. This discrepancy is significant in patients with lung and renal malignancies. Patients with Myeloma did well as per the prognostic scores.

Prognostic scores are not uniformly effective in all types of malignancies. Factors like delayed presentation and general condition were not included in the prognostic factors. Hence, we conclude that we cannot make a decision purely based on the prognostic scores to perform either palliative or definitive surgery.

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients.

Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009.

Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort.

All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group.

Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future.

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst.

A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score.

Overall patient satisfaction was recorded on a scale of 0-10.

38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group.

Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications.

Purpose: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial. Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience. To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs.

Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart. All patients reviewed at three months interval in a dedicated epidural follow up clinic and one-year postal and telephonic follow-up. Exhaustive epidural database maintained. VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment, at three months follow-up and one year. Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases.

Results: In the largest single series to date, we report on 928 consecutive patients, with three months follow-up and 354 patients with 12 months follow-up. Fifty-eight percent were females, 24% smoked and 4.1% had ongoing litigation due to their pain. The mean age was 56 years with BMI ranging from 17 to 50 (mean=28). Ten (0.6%) patients required subsequent surgical intervention due to disc herniation. The mean VAS, ODI and HADS improved significantly at three months and one-year results were encouraging.

Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms achieved facilitating onward referral for physical therapy. Subgroups predicting poor outcome are identified. Positive primary care feedback encourages further recruitment.

Background: Recent evidence suggests that surgical intervention with radiotherapy is superior to radiotherapy alone. Predicting the life expectancy is critical in decision making whether to go for palliative or definitive surgery.

Aim: To assess the accuracy of Modified Tokuhashi’s score (MTS) in predicting survival in patients with metastatic spinal tumours and cord compression; and to assess the incidence and role of early referral and diagnosis.

Material and Methods: In this retrospective study, we collected two years’ data. Medical record was reviewed for the source of referral, delay in symptom onset to diagnosis and treatment, types of tumours, Karnofsky score to assess patients’ disability, Modified Tokuhashi score to assess the expected survival and final outcome.

Results: 37 patients were included. Age ranged from 39 to 87 years(avg:64, median:66).30%(n=11) patients presented with cord compression and 70%(n=26) with instability pain. Cancer diagnosis had already been established in 57% cases off which 57% were referred from oncology and 43% from haematology. Remaining 43% patients were referred from GPs(68%) and medical specialties in the hospital(32%).51% patients presented early(< 3 months) and 22% presented late(> 6 months). Functional outcome improved in 58% patient following surgical intervention in early referral group(avg MTS:9.45) and improved in 61.5% patients in late referral group(avg MTS:9.5).

In patients with cord compression, average MTS was 6.6. Expected survival was < 3 months in 45.4% and 3–12 months in the remaining patients. 81%(n=9) patients of this group had surgical intervention resulting in satisfactory functional outcome in 36%. 3 patients had surgery done within 24 hours and another 4 within 72 hours(median:58).

In patients without cord compression, average MTS was 10.1. Expected survival was > 12 months in 84%. Surgical intervention was done in 84.6%(n=22) patients. 43% patients had posterior decompression and stabilisation with average MTS of 8.5 and satisfactory outcome in 56% patients. 13.5% patients had 2-stage anterior and posterior stabilisation with average MTS of 11.2 and satisfactory outcome in 100%. Average time from referral to definitive treatment was 17 days(mean:8, mode:8). Overall functional outcome was satisfactory in 84% patients.

30% patients died subsequently due to deterioration of their tumour-related problems with mainly Lung CA(36%) and Lymphoma(36%). Average MTS in these patients was 6.8. 5 patients died within 3 months of surgery.

Conclusion: Modified Tokuhashi score was consistent with patients’ expected survival and functional outcome. There was no major difference in functional outcome in relation to early or late referral. We conclude that Modified Tokuhashi score is helpful to make a decision for intervening surgically.

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

In recent years various surgical morphoplastic techniques have been employed in an attempt to improve on the disappointing natural history of this manifestation of biological failure.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies.

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining Visual Analogue Pain Score (VAS), vertebral height, vertebral and kyphosis angles, Oswestry Disability Index and Hospital Anxiety and Depression Score (HADS).

50 patients in our kyphoplasty group have undergone 91 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.8 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.3 and 2.7 respectively (p< 0.001).

Functional status ODI scoring improved from a pre-operative score of 54 to 47 post-operatively, to 40 at 6 weeks, and further, to 39 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.0, 11.2, 11.1 and 11.7 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle (p< 0.01) with increases in the anterior, middle and posterior vertebral body heights of 19, 31 and 9% respectively (p< 0.001). No significant improvement of kyphosis angle was identified.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.

Very few reports exist regarding use of intra-operative autologenous transfusion in adult spinal fusion surgery. Specific indications for use of cell saver in thoraco-lumbar spinal instrumentation are not clearly determined. Our objective was to identify the clinical factors associated with increased risk of intra-operative blood loss. To analyse the safety and benefits of using cell saver and to determine the cost-effectiveness.

51 consecutive thoraco-lumbar instrumented fusion over 14 months reviewed. There was no randomisation. Cell saver group consisted of 25 patients and control group consisted of 26 cases. Patients with degenerative scoliosis and tumours excluded. Clinical notes were reviewed.

Demographic data were comparable between the two groups. Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group. Levels of fusion ranged from 1–7 (Mean=2.8) in the cell saver group and 1–4 (Mean=1.9) in the control group. Mean duration of surgery was 15 minutes longer in study group. Intra-operative blood loss was higher in cell saver group (mean=1245 mls vs 800 mls). Significant indicators for duration of surgery were number of levels fused (p< 0.0001), patient weight (p=0.003) and revision surgery (p=0.029). Significant indicators for predicting blood loss were number of levels fused (p< 0.001) and duration of surgery (p=0.0304). 20% in study group (8 units of red cells) and 26% in control group (17 units of red cells) required blood transfusion. Percentage drop in the post-operative haematocrit was 19.1 in study group compared to 36.3 in control group.

In conclusion, 44.38% blood salvaged (35–38% in spinal literature). Use of cell saver significantly decreased post-operative need for blood transfusion. Number of levels of fusion, duration greater than 4 hrs and a low pre-op Haemoglobin/Haematocrit were significant parameters in predicting intra-operative blood loss. If blood loss is less than 700 mls, gains from cell saver are debatable.

Aim: In sub-axial cervical vertebrae the lamina appears to project perpendicular to the ipsilateral pedicle axis, and forms a reliable trajectory for avoidance of vertebral artery injury in lateral mass (LM) screw placement: the aim is to confirm these observations.

Material and Methods: 51 digital cervical spine CTs (255 vertebrae; 25 female 26 male; mean age 37.4 range:18–80). Exclusions: Severe degeneration, malformation, tumour, trauma.

Measurement (axial view):

Angle of ipsilateral outer lamina cortex to pedicle axis

Results: Average lamina-pedicle angle (standard deviation):

Females: Right: C3–84.8°(2.6), C4–85.2°(3.1), C5–86.7°(3.3), C6–89.2°(2.5), C7–92.3°(2.4);

Conclusion: The angle formed by the lamina and ipsilateral pedicle ranges from 84° at C3 to 92° at C7. Although the angle is not exactly perpendicular at all levels as hypothesised, the lamina forms a useful reference plane for pedicle screw insertion in the sub-axial cervical spine.

LM screws placed parallel to the lamina find sufficient LM width and are highly unlikely to injure the vertebral artery in bi-cortical placement. This technique appears favourable over conventional 30° LM placement.

Ethics approval: None needed

Interest Statement: None

Background: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial.

Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience.

Objectives: To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs.

Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases to measure pain relief, physical and psychological function.

Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart.

A standard mixture of 80 mgs of triamcinalone plus 7 mls of 1% lignocaine plus 5 mls of 0.9% saline used for all patients.

Results: In the largest single series to date, we report on 628 consecutive patients, with 3 months follow up.

58 % were females, 24% smoked and 4.1% had ongoing litigation due to their pain.

Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms was achieved facilitating onward referral for physical therapy, which is fundamental in optimising outcomes.

Long term follow-up is underway.

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. These published case series report the use of several end points, variously including Visual analogue score (VAS), Vertebral height, kyphosis angle and Oswestry disability index (ODI).

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining VAS, vertebral height, vertebral and kyphosis angles, ODI and hospital anxiety and depression score (HADS).

40 patients in our kyphoplasty group have undergone 70 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.9 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.7 and 3.8 respectively.

Functional status ODI scoring improved from a pre-operative score of 53 to 48 post-operatively, to 42 at 6 weeks, and further, to 41 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.3, 12.0, 10.1 and 11.3 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle with increases in the anterior, middle and posterior vertebral body heights of 26, 40 and 11 % respectively. Kyphosis angle has been improved by a mean angle of 2 degrees.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.

Background: Cell Saver technique using intra-operative autologenous transfusion known to conserve homologous blood resources.

Specific indications for use of cell saver in thoracolumbar spinal instrumented fusion not clearly determined.

No previously published literature from Britain to our knowledge.

Objectives: To identify the clinical factors associated with increased risk of intra-operative blood loss.

To analyse the safety and benefits of using cell saver technique.

Method: A total of 51 consecutive spinal instrumented fusion cases during last 14 months reviewed.

There was no randomisation; use of cell saver was at surgeon’s discretion.

Results: Demographic data including age, weight, smoking and prior surgery were similar between the two groups.

Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group.

Conclusion: 44.38% blood salvaged (35–38% in spinal literature).

Use of cell saver significantly decreased the risk of post-operative need for blood transfusion.