This is a preliminary retrospective report on a novel technique for achieving fusion at the lumbo-sacral disc. Current methods of complete discectomy and instrumented fusion involve either a posterior approach and the insertion of cages or an anterior approach. Both methods involve quite extensive dissections with potential stabilising muscle stripping. They also require significant post operative analgesia, inpatient stay and post operative recovery. There are attendant risks of nerve injury, blood loss and thrombosis.

A novel method of approach from the sacrum via a ‘safe zone’, described by Yuan et al., is presented. The technique along with the anatomical considerations is described. The operation basically consists of a posterior sacrococcygeal incision and an x-ray guided approach to the anterior surface of the S1/S2 junction with blunt obturators. The L5/S1 disc is then accessed by drilling through the sacrum. The disc is then removed from within with shaped tools leaving the bulk of the annulus. The void created is filled with bone graft and the L5 vertebra fixed to the sacrum via a bolt. The initial results of the first 20 patients are presented. 21 patients have been operated upon but one has been lost to follow up due to a psychological disorder. That patients details have been excluded.

The patients underwent surgery between 4/7/06 and 8/10/07. All operative procedures were completed without complication, the operative time improving from 60 minutes to a ‘standard’ 45 minutes. There were no post operative complications. Two patients underwent additional procedures. One was an L4/5 Wallis ligament the other an inter-transverse non instrumented fusion. Several patients required a further pain control procedure, 3 caudal epidurals, 2 facet blocks and 2 coccyx injections. One patient required an L4/5 PLIF 12 months after the first procedure and two patients required posterior stabilisation at the same level. One after 4 months the other at 18 months.

The indications for surgery are the same as for a standard fusion procedure. In this group there were 12 degenerative discs with mechanical LBP, 3 spondylolistheses, 2 previous failed posterior fusions and 3 post discectomy patients. Discography was used for confirmation of the pain source in 15 cases. The duration of symptoms ranged between 2–15 years with a mean of 6.25. There were 12 male and 8 female patients. The age ranged between 34–70 with a mean of 47. The female mean being 48 and the male 46.

The Oswestry disability index showed a mean of 47 pre-operation and 23 post-operation. 13 out of 20 have been discharged with symptoms resolved or easily bearable. The hospital stay varied between 1 night and 4 nights with a mean of 3.3.

This novel approach to the lumbar spine gives rapid and safe access to the lumbar disc space despite the unusual approach for spinal surgeons. Once the initial incision is made the procedure is carried out under x-ray control using techniques which are very familiar to Orthopaedic surgeons. The lack of intra-operative problems and post-operative complications testify to a safe procedure.

The question mark remains on the rate of fusion. Two patients and potentially a third required a secondary posterior instrumented fusion. One was due to demonstrable loosening of the bolt and the other two continued pain possibly due to inadequate stabilisation. In my view, despite the European teaching, posterior instrumentation is desirable. This can be achieved via a percutaneous technique.

This is a preliminary report on a novel technique for achieving fusion at the lumbo-sacral disc. Current methods of complete discectomy and instrumented fusion involve either a posterior approach and the insertion of cages or an anterior approach. Both methods involve quite extensive dissections with potential stabilising muscle stripping. They also require significant post operative analgesia, inpatient stay and post operative recovery. There are attendant risks of nerve injury, blood loss and thrombosis.

A novel method of approach from the sacrum via a ‘safe zone’, described by Yuan et al., is presented. The technique along with the anatomical considerations is described. The initial results of the first 15 patients are presented.

We feel this is an approach with some merit in terms of ease and speed of operation, quickness of recovery by patients and reduction of complications.

Aim: To determine the need for caudal epidural steroid injections to be administered with a mixture containing local anaesthetic.

Patients: 100 consecutive patients listed for caudal epidural by two spinal orthopaedic consultants with lum-bosacral radiculopathic pain. 19 patients did not fulfil the criteria for the trial.

Methods: Subjects randomised to either steroid injection (80mg triamcinolone) with 18mls 0.25% bupivicaine or steroid injection with 18mls Normal saline. Pre-injection maximal (Pmax) and average (Pav) pain scores and Oswestry Disability Index (ODI) scores were obtained for each patient. Pain scores were repeated at 48 hours, 2 weeks and 8 weeks with a second ODI.

Results: A significant improvement in both Pav and Pmax were seen over the study period for both groups. There was no significant difference in either group for ΔPav. or ΔPmax at any stage of the study. Those patients who received a mixture containing bupivicaine underwent a significant improvement in their ODI in contrast to those who were injected with the saline mixture. There was also a significant difference in the ΔODI between groups.

Conclusion: Epidural bupivicaine injection appears to enhance the effect of epidural steroid injection with adequate levels of monitoring and access to specialist support. There may be a beneficial effect on the local pain pathways by the local anaeasthetic that outlasts the direct pharmacolgical effect.

Treatment regimes for malignant disease have improved significantly in recent years leading to improved survival after diagnosis of primary and Metastatic disease. Against this background we have reviewed the activity in a district general hospital offering a spinal service to evaluate the efficacy of surgery in metastatic disease. Materials and Methods: Retrospective casenote review of patients identified through theatre records over a 3 year period. 27 patients were identified as having surgery for spinal tumours, of whom 24 were for metastatic disease. All presented with pain and/or signs of acute cord compression and had an intervention on an urgent or emergency basis by one of three spinal surgeons. Results: Of the 24 patients with metastases, the primary tumours were breast (7), lung(7), prostate(2), renal(2), bladder(1), clear cell (1), colon(1), thyroid(1) and unknown (2). The operations performed were: spinal decompression or vertebrectomy and stabilisation(18), stabilisation without decompression(4), decompression alone (1), biopsy only (1). Mean survival after surgery was 9.4 months (range 0–42 months) with a poorer outcome in those with pulmonary and renal disease. 7 patients remain alive with a mean follow up of 21 months. Symptomatic improvement was recorded in 19 / 24 patients in terms of pain control and/or restoration of function. There were 4 perioperative deaths of which none were due to complications of surgery.

Discussion: Patients with terminal diseases are challenging to treat as they require multidisciplinary input both in hospital and in the community. Good results can be achieved for both symptom control and pain relief by surgical intervention for spinal metastases if appropriate early referral is made to a spinal surgeon. We have found that with the general improvements in survival with malignancy an aggressive surgical regime of decompression or vertebrectomy with spinal stabilisation can be supported.