Background

The majority of adults will experience an episode of low back pain during their life. Patients with non-specific low back pain and lumbar disc degeneration (LDD) may experience spinal pain and morning stiffness because of a comparable inflammatory process as in patients with osteoarthritis of the knee and/or hip. Therefore, this study assessed the association between spinal morning stiffness, LDD and systemic inflammation in middle aged and elderly patients with low back pain.

Aims. Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. Methods. In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK. Results. The 188 patients, all under the age of 55 years, underwent 196 LS lumbosacral MRI scans for suspected CES. Of these patients, 14 had cauda equina compression and underwent emergency decompression. No cases of CES were missed. Patients spent a mean 9.9 minutes (8 to 10) in the MRI scanner. Conclusion. Our results suggest that a LS lumbosacral MRI could be used to diagnose CES safely in patients under the age of 55 years, but that further research is needed to assess safety and efficacy of this technique before changes to existing protocols can be recommended. In addition, work is needed to assess if LS MRIs can be used throughout the spine and if alternative pathology is being considered. Cite this article: Bone Joint J 2020;102-B(4):501–505

Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Aims. The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life. Patients and Methods. This prospective cross-sectional study included 479 adult patients with back pain from a university spine centre. Each completed SF-12 and Oswestry Disability Index (ODI) questionnaires and underwent standard spinal examinations to elicit Waddell signs. The relationship between Waddell signs and age, gender, ODI, Mental Component Score (MCS), and Physical Component Score (PCS) scores was determined. Results. Of the 479 patients, 128 (27%) had at least one positive Waddell sign. There were significantly more women with two or more Waddell signs than men. The proportion of patients with at least one positive Waddell sign increased with age until 55 years, and then declined rapidly; none had a positive sign over the age of 75 years. Functional outcome scores were significantly worse in those with a single Waddell sign (p < 0.01). With one or more Waddell signs, patients’ PCS and ODI scores indicated a perception of severe disability; with three or more Waddell signs, patients’ MCS scores indicated severe disability. With five Waddell signs, ODI scores indicated that patients perceived themselves as crippled. Conclusion. Positive Waddell signs, a potential indicator of central sensitization, indicated a likelihood of having functional limitations and an impaired quality of life, particularly in young women. Cite this article: Bone Joint J 2018;100-B:219–25

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

To prospectively determine the relationship between the two most commonly used generic spinal outcome measures, the Oswestry Disability Index (ODI) and the Low Back Outcome Score (LBOS). Outcome measures inform audit and research. Few spine surgical specific outcome measures are in general use. Generic measures are used for a variety of spinal disorders it is not known which is best or exactly how they relate for different conditions. Pre-operatively and two years post surgical results were available in 240 patients. There were 125 males, 115 females. Sub groups numbering 82 discetomy, 78 decompression, 26 revision and 19 fusions were analysed. Average age 55 years (range 23-88). The pre op average ODI was 55% and the LBOS was 29. Correlation was -0.73. The overall post operative score at 2 years was 34% ODI and 37 LBOS, the correlation was better at -0.87. The correlation between the two scores post operatively was very good for Discectomy surgery (-0.916) and fusion surgery (-0.907) but not so close pre operatively with Discectomy (-0.786) and fusion correlation poor at (-0.302). Revision surgery and decompression surgery had similar good correlation post operatively. The correlation of both outcome measures to the Modified Zung depression index was poor. The poor pre operative correlation suggests that thresholds for surgery cannot be compared within registries using different measures. The post operative scores and change in scores correlate better. This is important in comparative studies using different outcomes scores within the same spine registry. No conflict of Interest. Registered database and audit of service standard

We have studied two matching cohorts of patients treated by Dynesys flexible stabilisation with and without hydroxyapatite (HA) coating of the pedicle screws. From our series of 570 Dynesys procedures, we studied patients with HA coated screws with a minimum one year follow-up. Patients were entered prospectively and followed up at 6 weeks, 3, 6, and 12 months and annually thereafter. Plain radiographs were obtained annually. 58 patients (26 males, 32 females, mean age 55 years at surgery) underwent Dynesys stabilisation with HA coated screws. The data was compared with 69 patients who underwent Dynesys stabilisation with non-coated pedicle screws between 2004 and 2006 (26 male, 53 female, mean age 54 years). Outcome measures were screw loosening, breakage, implant removal or revision. A total of 320 HA coated pedicle screws were inserted. 12 patients were lost to follow-up. 2 patients underwent subsequent level extension, and 2 had their implants removed. There were four screw breakages in three patients, all affecting S1 screws. There was no evidence of screw loosening in any patient. In the non-HA coated group 354 pedicle screws were inserted. 5 patients required revision or subsequent surgery. 12 patients had screw loosening and required implant removal. There was a significant improvement of anchorage of the HA coated screws. Change to HA coating was investigated because of high loosening in plain screws. The improvement has been highly significant. Flexible stabilisation is a better model than fusion because the implant remains under constant load. Disclosure: The authors did not receive any outside funding in support of preparation of this work

Purpose of study. The Royal College of Radiology (RCR) provides guideline criteria to order lumbar spine X-rays for back pain. An audit was undertaken in our hospital to see compliance with this guideline. Methods. 200 lumbar spine radiology requests received in the hospital radiology department from General Practitioners over a 12 month period were identified. These 200 requests and their corresponding radiology reports were retrospectively analyzed. Results. Out of the 200 patients 80 were male and 120 were female. 1 patient was < 18 years, 75 patients were between 18 and 55 years, 52 patients were between 55 and 70 and 72 patients were > 70 years of age. Only 125 patients satisfied the RCR criteria for requiring a Lumbar Spine X-ray. 104 of these 125 patients met the criteria only because of age (> 55). The remaining 21 had other criteria like history of malignancy, osteoporosis or trauma that required imaging. Of the 200 X-rays the only significant pathology that was identified from the report was osteoporotic fractures in 35 patients. The most commonest diagnostic report was spondylosis which was seen in 92 patients. Among the 75 patients between the age of 18 and 55 only 2 fulfilled the criteria for requiring a lumbar spine X-ray. Hence 73 (36.5%) X-rays were outside the criteria. Among the 52 patients between the ages of 55 and 70 only 6 had a criteria other than age. Conclusion. This limited study demonstrates the following two possibilities. More stricter adherence to guidelines in patients aged 18 to 55. In this study 73 (36.5%) X-rays could have been avoided by this method. We believe that there is a case for the college to increase the age related criteria from 55 to 70 to be at par with American guidelines. If this method was used an additional 46 (23%) X-rays could have been avoided

Degenerative spondylolisthesis is four times more common in women than in men. Although this gender difference has long been recognised there has been no explanation for it. We have examined the radiographs and CT scans of 118 patients over the age of 55 years and of a control group under the age of 46 years. Our findings confirmed the presence of more sagittally-orientated facet joints in patients with degenerative spondylolisthesis but did not show that the gender difference can be explained by the morphology of the facet joint. Furthermore, we conclude that the increased angle of the facet joint is the result of arthritic remodelling and not the primary cause of degenerative spondylolisthesis. It is more likely to be due to loss of soft-tissue resilience with subsequent failure of the facet joints which are acting as the last restraints to subluxation

Aims. The aim of this study was to evaluate the time course of changes in parameters of diffusion tensor imaging (DTI) such as fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in patients with symptomatic lumbar disc herniation. We also investigated the correlation between the severity of neurological symptoms and these parameters. . Patients and Methods. A total of 13 patients with unilateral radiculopathy due to herniation of a lumbar disc were investigated with DTI on a 1.5T MR scanner and underwent micro discectomy. There were nine men and four women, with a median age of 55.5 years (19 to 79). The changes in the mean FA and ADC values and the correlation between these changes and the severity of the neurological symptoms were investigated before and at six months after surgery. . Results. The mean FA values were significantly lower (p = 0.0005) and mean ADC values were significantly higher (p = 0.0115) in compressed nerves than in intact nerves. Although the FA values increased significantly at six months after surgical treatment (p = 0.020), the ADC values decreased but not significantly (p = 0.498). There were strong correlations between the DTI parameters such as the FA value and the severity of the neurological symptoms as assessed using the Japanese Orthopaedic Association (JOA) score and the Roland-Morris Disability Questionnaire (RDQ). . Conclusion. This preliminary study suggests that it may be possible to use DTI to diagnose, quantitatively evaluate and follow-up patients with lumbar nerve entrapment. Take home message: DTI is a potential tool for functional diagnosis of lumbar nerve damage. Cite this article: Bone Joint J 2016;98-B:387–94

Aims

The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS).

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes.

A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group.

In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes.

Cite this article: Bone Joint J 2013;95-B:81–9.

The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR).

Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR.

Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°).

These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.

We have treated 175 patients with a chordoma over a ten-year period. Only two had a family history of the condition and we describe these in this paper. In one patient the tumour was at the craniocervical junction and in the other the lesion affected the sacrum. We have undertaken a literature review of familial chordoma and have identified chromosomal abnormalities associated with the condition.

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.