STUDY DESIGN

Retrospective review of outcome of submuscular rod placement without apical fusion for the treatment of scoliotic deformities in children with severe co morbidities (ASA IV).

To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity

Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence

24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up

Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices

Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%).

Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved.

To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery.

Retrospective

37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values.

Amount of perioperative blood transfusion, costs

14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case.

The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial.

A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use.

A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications.

Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate.

The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes.

This study did not require ethics approval and no financial support was received.

Plain radiography has traditionally been used to investigate and monitor patients with adolescent idiopathic scoliosis. The X-ray allows a calculation of the Cobb angle which measures the degree of lateral curvature in the coronal plane. ISIS2 is a surface topography system which has evolved from ISIS, but with much higher precision and speed. It measures the three dimensional shape of the back using structured light and digital photography. This system has the benefit of not requiring any radiation. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane. The aim of this study was to compare this parameter to the Cobb angle measured on plain X-ray.

Twelve patients with idiopathic adolescent scoliosis underwent both a standing AP spine X-ray and an ISIS2 scan on multiple occasions. Both scan and X-ray were done within one month of each other. No patient underwent surgery during the study period. The Cobb angle and the degree of lateral asymmetry were calculated.

Twelve patients mean age 12.5 years (range 10-16) were investigated using both ISIS2 and X-ray. They had a mean 2.3 (1-5) combined investigations allowing for 30 comparisons. The correlation between the two measurements was r =0.63 (p=0.0002). The Cobb angle measured on ISIS2 was less than that measured by radiograph in 27 out of 30 comparisons. The mean difference between the measurements was mean 6.4° with a standard deviation of 8.2° and 95% confidence interval of 3.3° to 9.4°.

In adolescent idiopathic scoliosis, curve severity and rib hump severity are related but measure different aspects of spinal deformity. As expected, these relate closely but not precisely. ISIS2 offers the promise of monitoring scoliosis precisely, without adverse effects from radiation. The small numbers in this series focus on the group of patients with mild to moderate curves at risk of progression. In this group, ISIS2 was able to identify curve stability or progression, without exposing the subjects to radiation.

Background

In suspected scaphoid fracture the initial scaphoid series plain radiographs are 84-94% sensitive for scaphoid fractures. Patients are immobilised awaiting diagnosis. Unnecessary lengthy immobilisation leads to lost productivity and may leave the wrist stiff. Early accurate diagnosis would improve patient management. Although Magnetic Resonance Imaging (MRI) has come to be regarded as the gold standard in identifying occult scaphoid injury, recent evidence suggests Computer Tomography (CT) to be more accurate in identifying scaphoid cortical fracture. Additionally CT and USS are frequently a more available resource than MRI.

We hypothesised that 16 slice CT is superior to high spatial resolution Ultrasonography (USS) in the diagnosis of radiograph negative suspected cortical scaphoid fracture and that a 5 point clinical examination will help to identify patients most likely to have sustained a fracture within this group.

Purpose: Few opportunities exist for physicians to easily obtain immediate insights or solicit direct advice from a respected peer on a complicated case. As a result, physicians end up relying heavily on journals, textbooks, and other dated resources that may prove to be dated or inadequate in addressing unique patient problems. Furthermore, the typical training modules available are limited to a one- or two-day experience. Often times this situation does not provide an adequate understanding of the surgical indications, techniques, and potential complications in the application of new technology. Consequently, many surgeons fail to adopt new technologies due to their lack of understanding of the application of such novel technologies. Recently, Reynolds et al studied the effect of peer collaboration among surgeons at a weekly surgery conference. They found that changes in surgical decision-making occurred in 12.5% of all cases reviewed and in 20% of the complex cases. However, collaboration should not be limited to weekly meetings or annual conferences. The Internet has introduced Collaborative Knowledge Networks (CKNs) that allow communities of surgeons to collaborate virtually on complex patient cases—allowing for rapid, bidirectional information. SpineConnect has surfaced as an example of a CKN that allows orthopedic spine surgeons to discuss surgical decisions.

Method: We studied the use of Internet collaboration among spine surgeons using the SpineConnect website. We also compared the improvement in the adoption rate of novel technologies using technology fellowships versus traditional training modules. These fellowships use both in-person and virtual collaboration through the Spine-Connect platform as a new means of training physicians.

Results: Using the SpineConnect website, surgical decision-making and planning was altered in 34% of active users and 90% agreed that the ability to collaborate with their peers, using a dedicated website, has improved their ability to practice spinal surgery. Continuous communication and dialogue resulting from the technology training fellowships encouraged better understanding of surgical indications, a greater comprehension of surgical technique, and a mechanism to discuss and solve complications. When such fellowships were implemented, we found a 30% improvement in adoption rate over traditional training modules.

Conclusion: The treatment of spine surgery patients has benefited from the utilization of collaborative platforms such as SpineConnect. In spine surgeon training and education, we found that CKNs promoted better surgical decision-making and increased understanding of new technology application.

We investigated the effect of neck dimension upon cervical range of movement. Data relating to 100 subjects healthy subjects aged between 20 and 40yrs was recorded with respect to age, gender and ranges of movement in three planes. Additionally two commonly used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool the CROM goniometer (Performance Attainment Associates, Roseville, MN).

Using multiple linear regression analysis it was determined that sagittal flexion (P= 0.0021) and lateral rotation (P< 0.0001) were most closely related to neck circumference alone whereas lateral flexion (P< 0.0001) was most closely related to a ratio of circumference and length. The uniplanar goniometer has some usefulness when assessing neck motion, comparing favourably to chin-sternal distance that has almost no role.

Neck dimension should be incorporated into cervical functional assessment. One should be wary about recorded values for neck motion from non-validated measurement tools.

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.