Background

Low back pain (LBP) with or without leg pain, is one of the most common causes of pain and disability and a frequent cause of attendance to emergency departments (ED). Increasing numbers of patients create a difficult challenge for clinicians to effectively and appropriately manage patients with LBP in an urgent care setting.

Introduction

Many journals require outcome data at 2 years post-operative for the assessment of operative procedures in spinal surgery. This study seeks to clarify the timescale of improvement after surgery to see if a shorter period of assessment will indicate the final outcome.

Audit is an important part of surgical practice. Commissioners may use it as evidence of quality assurance. No comprehensive audit exists in spinal surgery. Usage of existing databases is disappointing. We developed an audit database which was comprehensive and gathered patient outcomes. The underlying principles were:

All patients having surgery should enter,

Demographic data, OPCS codes, length of stay and other data were downloaded directly from the hospital information systems. A monthly printout of patients enrolled was provided to the audit coordinator. She was responsible for the collection of clinical outcomes at 6 months, 12 months, and 2 years after surgery. The initial audit involved the Northwest and Mersey Regions. Data from the hospital information systems (HIS) for two years were available for comparison. Unfortunately only two centres gathered clinical outcomes. We have continued to gather data. 380 patients have been enrolled. HIS data are available for all. With varying lengths of follow up, there are 1045 potential clinical outcomes available. Only 8 patients (2%; 8 outcomes, 0.76%) have been lost to follow up. Using this data we are able to compare outcomes between surgeons, between surgical procedures, and see changes over time. As far as we know we are the only centre in the UK able to do this. It is a valuable Clinical Governance tool. We believe that the principles underlying this audit are the only means to obtain comprehensive outcome audit in surgery.

Aim: To test the null hypothesis that interbody cage fusion does not improve clinical outcome.

Methods and materials: This is a prospective study of 87 patients. Seventy-one of the 87 patients followed to the conclusion of the study at two years. Inclusion criteria: Patients undergoing interbody cage fusion with the Ray threaded cage, made of Titanium, and posterior stabilisation with Diapason pedicle screw instrumentation, all operated by the same surgeon. Exclusions: Surgery for infection, or tumour. Tools used for assessment: Oswestry low back pain questionnaire; Visual analogue pain score (VAS); SF36 general health questionnaire. Assessment time points were 1) Pre-op, and post-operatively at 2) 3 months, 3) 6 months, 4) 1 year and 5) 2 years. SF 36 was introduced later recruiting 71 of the 87 patients.

Results: There were 31 males and 56 females. Average age was 46 years (range 14–76) Fifty-one of the patients had no previous surgery, while 36 had previous surgery.

There was a significant, gradual improvement in symptoms of an average of 20 points (p< .001) over the first year on the Oswestry score. However, this plateaued between the first and second years. Over two years there was a greater than 20 point increase in all but three concepts of SF36, general health, reported health and mental health improving around 15 points (p< .001). Sixty-five per cent of the patients reported an overall improvement and 12% were worse, with most changes occurring in the first year.

In assessing the symptoms with Oswestry questionnaire there was a significant difference between first time and revision surgical groups. The revision group showed an improvement of 11 points (p< .001) at two years, most occurring in the latter part of the first year followed by some deterioration between the first and second years. In the primary surgery group there is a 28 point (p< .0001) improvement by two years. Most of the improvement in the primary group is achieved by the first six months.

Conclusions: Interbody fusion can significantly improve health and function assessed by Oswestry and SF36 outcome tools. Additional observations – unsatisfactory outcome in 12% of patients; expected progress at fixed times after surgery can assist planned rehabilitation. This paper introduces the concept of time staged assessment of symptoms in spinal fusion.

Aim: To test the null hypothesis that older instrumentations with their complications do not produce a clinical improvement.

Introduction: Surgical treatment of adult scoliosis is difficult with a high incidence of complications. The presenting complaints and expectations from the surgery are different to those in adolescent scoliosis.

Methods and results: Inclusion: All cases of adult idiopathic scoliosis presenting at or after the age of 20 and requiring surgical treatment. Exclusions: Revisions. Average age of follow-up is 6 years (range 2 to 14 years) with 107 patients. For analysis three groups were decided on the basis of the age. A number of different instrumentation systems were used with time. Treatment varied according to senior author’s planning for the individual patient, ranging from posterior instrumentation, anterior release and posterior instrumentation, and combined anterior and posterior instrumentation.

Group I: Age 20–30 years, consisted of 64 patients. Average pre-operative primary curve was 56° with post-operative correction 50%. Deformity was the most common presenting complaint. Seventy-one per cent felt an overall improvement, the rest noticed no benefit.Twenty-two per cent would prefer not to have the surgery. Complications included four pseudoarthrosis, nine required further surgery, and one late infection.

Group II: Age 31–40 years, 20 patients with an average primary curve of 63°, and a correction of 56%. Fifteen per cent had significant pain at presentation. Seventy per cent felt an overall benefit although all noticed a cosmetic improvement. Complications: two pseudarthrosis, three subsequent surgical procedures.

Group III: Age > 41 years, 23 patients, an average primary curve of 72° with a correction of 39%. Eleven out of 23 had significant pain on presentation. Complications: four pseudoarthrosis, metal pull out in one. Further surgery was performed in nine. All felt some benefit from the treatment and despite the high proportion of complications, would have the surgery again.

Conclusions: There is a clinical benefit from surgical treatment of adult idiopathic scoliosis. There is a higher number of complications in the older age group.

Aim: To test the null hypothesis that plain X-rays can provide the same assessment of sacral screw placement as CT.

Introduction: Engaging the anterior cortex of the sacrum provides additional strength to fixation and is a goal of surgery. The sacrum with its unique anatomy makes it a difficult bone to assess screw placement radiologically. This study examines the positioning of sacral screws as seen on X-rays and compares the result with spiral CT “gold standard”.

Materials and methods: Inclusion criteria: Sacral fixation using Diapason (Stryker) Titanium pedicle screws by one surgeon. Spiral CT, plain AP and lateral X-rays of the sacrum. Exclusion criteria: X-rays with more than three level fixation.

There were 66 patients (132 S1 screws). Surgical technique engaged the anterior cortex to enhance fixation. Two independent observers (a musculoskeletal radiologist and spinal fellow) who were blinded to outcome, reported findings in forms with constrained fields. Assessment of plain X-ray and CT was at separate times not less than three weeks apart. Variables noted: Screw position in pedicle, screw tip position, and angle of screw (sagittal on axial CT scans).

AP X-ray was divided, for each screw, into nine zones based on the first sacral foramina. The position of the screw tip in the zones was noted. The lateral X-ray was divided into three zones to note the tip of the screw in relation to the cortex. The extent of screw protrusion was measured. X-ray technique: Supine AP centred on fusion and lateral X-ray standing, X-ray source 200 cm from the film. CT: Images acquired on Picker PQ 6000 spiral CT with collimated thickness of 3 mm, pitch 1.25 and reconstructive index of 1.Para-sagittal and coronal reconstructions. Spiral CT was used to note the position of the screw within the pedicle and the relation of the screw tip to the anterior cortex. For screws within the pelvis any structure in close proximity was noted.

Results: On CT 10% of the screws had breached the pedicle compared with 2% on the plain X-rays. Anterior cortical perforation had been achieved in 48 out of 132 screws on CT. The sensitivity of the plain X-rays to perforation was 40% with a specificity of 92%. There was an average under estimation of the extent of screw perforation by 4.4 mm (95% confidence ±1 mm). There was a correlation between the position of the screw tip on the AP X-ray and the sensitivity of the lateral X-ray to detect a perforation. The sensitivity ranged from 52% for zone 1 to 15% in zone 8. 15/31 perforations were missed in zone 1, compared with 11/13 in zone 8. For screws penetrating 5 mm or more, in zone 8, 9 out of 10 were missed on lateral X-rays.

Eighty-five screws were placed at an angle of less than or equal to 25° to the sagittal; this included 28 out of 34 screws placed in zone 8. The inter-observer variance of screw angle measurement was 1.1° and intra-observer difference 1.7°. Overall 95% confidence of a single measurement was ±3.3°.

Conclusion: Plain X-rays and CT do not provide the same assessment of sacral screw placement. This is particularly true for sagitally placed screws with screw tips in zones 7–8.