Lumbar spinal surgery may be associated with considerable pain in the early postoperative period. This often leads to a delay in patient mobilisation and a consequent increase in the risk of developing perioperative complications. Several studies have demonstrated the efficacy of intrathecal opioids for analgesia following spinal surgery. 1. –. 3. Morphine has been the most widely studied opioid and although improved analgesia has been reported with its use the risk of serious side effects such as respiratory depression has resulted in patients having to be nursed postoperatively in a high dependency unit. 2. Intrathecal diamorphine has been widely used for analgesia following lower limb joint replacement where it is an effective analgesic agent with a good safety profile. 4. –. 5. Its use for analgesia following lumbar spinal surgery has never been reported. We present our experience of using intrathecal diamorphine for analgesia following lumbar spinal surgery. Data were collected on all patients undergoing surgery who received intrathecal diamorphine and stored on a database (Microsoft Access). Results: 194 patients received intrathecal diamorphine following spinal surgery over a 30 month period. All patients underwent lower lumbosacral decompressive and/or fusion surgery. Mean dose of diamorphine administered was 1.6mg (range 1–4mg or 20–50mcg/kg). In all cases intrathecal diamorphine was administered by the anaesthetist once the patient was anaesthetised. Only 9% of patients had a pain score of 2 or greater within the first 24 hours (using a verbal rating scale 0–10). No patients required rescue analgesia with intravenous opiates. All patients except one were nursed on a regular orthopaedic ward. Side effects were rare. Respiratory depression occurred in one patient necessitating supplemental oxygen and monitoring in a high dependency unit for 12 hours. Hypotension was an infrequent finding (3.5%) but was most common upon return to the ward and in the following 24 hours. It was easily treated with the administration of intravenous fluids and vasopressors were never required. Sedation occurred in 4 of the patients whilst in the recovery ward but the incidence was nil once patients had been discharged to the orthopaedic ward. The most common complication recorded was pruritis, occurring in 9% of patients within the first 12 hours. Conclusion: Intrathecal diamorphine is an effective and safe method of providing analgesia following lumbar spinal surgery. High Dependency nursing care is not required as the incidence of serious side effects is low

An independent audit of Lumbar Spinal surgery performed by a single surgeon over a 4 year period is presented. The three groups evaluated included Lumbar fusion, decompression and discectomy. Patients were assessed using the Oswestry Disability Questionairre and five other questions related to overall outcome and patient satisfaction. The minimum follow-up was 6 months. Patient response rate was 74%. The overall outcome was 81% Excellent/Good vs 19% Fair/Poor. The best outcomes were in the discectomy group. The decompression group showed a variable and unpredictable outcome. Complications encountered in the three subgroups are discussed. Lumbar spinal surgery offers lasting and predictable outcomes to a large majority of well selected patients. Independent surgical audits form an important part of evaluating one’s surgical practice

There is increasing knowledge regarding the functional outcome of patients following posterior lumbar spinal surgery for degenerative conditions of the spine. There is less known regarding the expectations patients have for spinal surgery and how that may relate to commonly reported surgical outcome measures. It was the purpose of this study to evaluate the results of elective lumbar spinal surgery as it relates to patient expectations for outcome. and outcome as quantified by both physician reported outcome and patient derived generic and disease-specific measures. Patient expectations for surgery were evaluated in one hundred and fifty-five consecutive patients undergoing posterior lumbar surgery for degenerative conditions (single institution, two surgeons). SF-36+Oswestry disability was quantified preoperatively, and serially postoperatively. Preoperative expectations (pain relief, sleep, recreational, ADL, work return) were documented and postoperative expectations quantified at time of anticipated maximal medical improvement (6mos decompressions,1yr with fusions). Mean preoperative SF-36 MCS and PCS scores were 3.4 and 1.2 S.D. below age/gender matched Canadian norms. Although patients reported improvements in SF-36+Oswestry scores following surgery, mean SF-36 MCS and PCS scores were still 2 and 1.5 S.D. below norms. Mean Oswestry disability improved from 48.7%±1.7% to 23.1±1.9%. Expectations for surgery were met in 81%(responders:143/155). Of 19%(27/143) where expectations were not met, 6/27 have either nonunion, technical, or medical factors. There was no difference in mean age, gender, comorbidity, procedure type and follow-up comparing patients where expectations were met to those that were not. Patients where expectations were not met reported lower preoperative SF-36 (GH and VT) domain scores (p=0.02 and 0.04, respectively), however, preoperative Oswestry, SF-36 MCS and PCS scores were not significantly different. Patients were less satisfied if they had prior lumbar surgery (p=0.02) or involved in WCB/litigation (p< 0.001). We note 15%(21/143) where expectations were not met and there were no apparent surgical or medical confounds to account. There are likely other factors that may influence patient perception and expectation for treatment which requires further study

Work in the clinical environment led to the identification of the need for an instrument that was capable of continuously monitoring lumbar spinal curves of patients with back pain in order to establish degree of compliance with therapist advice regarding posture and activity during their normal day. Additionally, work by others in the laboratory setting has started to reveal some differences in motion parameters between those with and without back pain. Although there are changes of, in particular, maximum angular velocity associated with pathology of the spine, these changes may be considered the effects of the pathology. By looking at motion parameters taken over longer periods of time, more subtle differences, hopefully more related to possible causes of back pain, may be eventually identified. Factors such as time spent at extremes of range of motion and degree of activity or inactivity may have as great an affect on the production of back pain as vibration and heavy physical load. Unfortunately, even those factors thought most likely to contribute to the onset of back pain have only ever been proven to explain a small percentage of cases. By logging lumbar spinal curves continuously over many hours, profiles of lumbar spinal usage can be calculated thus enabling study of the relationships between posture, activity and pain production. Conventional instrumentation can not be used in the users normal environment either because of bulk or interference from everyday appliances. A small optical fibre goniometer (OFG) and data logger has been developed that is capable of continuously monitoring lumbar sagittal curves. It is robust and suitable for use in normal working environments. For use on the lumbar spine, the instrument’s stiffness was kept to a minimum to make it as comfortable to wear as possible. This has resulted in an instrument that is capable of reproduction of standard curves, in a jig, with a RMS error of 1°. A stiffer instrument would produce smaller errors. Comparative studies against other instruments have been carried out but are not yet published. The instrument takes the form of a small base plate, designed to be glued to the skin over the sacrum, and a flexible rod that is held in place over the lumbar spinous processes by two guide tubes also glued to the skin. The OFG weighs 25g and the datalogger 250g. The OFG and logger can be run safely for over 30 hours at a maximum logging frequency of 50 Hz. The datalogger has a facility for entry of coded information via selector switches which allow the user to put markers on the data train which could be activity of pain behaviour related. Initial trials have been carried out using the instrument to obtain motion profiles of 80 “normal” individuals, 10 males and 10 females from each of 4 age groupings; 20 to 29; 30 to 39; 40 to 49; 50 to 59. Logging duration was normally six hours during their working day. Data was collected at 25Hz. It was established that the instrument was able to produce basic motion parameters that were similar to other instruments. Although, no significant differences in ROM were found with age there were significant differences found between males and females in terms of end range flexion and extension. Additionally, the amplitude of oscillations of spinal curve during walking was found to significantly decrease with age. This may have been indicative of general stiffening of the lumbar spine with age or associated with a possible decrease in walking speed with age. It is envisaged that the instrument will find use in both ergonomic analysis as well as the study of the management of back pain. Use of the instrument to investigate patient compliance with therapist advice is planned and will hopefully help to develop the management of patients with low back trouble. Future development of the instrument is hoped to include incorporation of a sensor to monitor the angle of the base plate, as this will allow better interpretation of the data from the logger post data collection. Additionally information of base plate angle will allow some simple load calculations to be made. Repeatability trials have been carried out using human subjects. Here, the major source of variability was found to be the subjects themselves. Reapplication error was found to be small, compared to subject variability. Comparison with measurements taken using the flexicurve technique and also the Skill System (similar to Isotrak or Fastrak) has been undertaken. Here the two systems were found to follow each other achieving correlation coefficients of 0.99. However, more critical forms of analysis revealed relatively large differences, although these were no greater than others that have compared the inclinometer technique with the flexicurve

Endoscopic spine surgery is a promising and minimally invasive technique for the treatment of disc herniation and spinal stenosis. However, the literature on the outcome of interlaminar endoscopic decompression (IED) versus conventional microsurgical technique (CMT) in patients with lumbar spinal stenosis is scarce. We analyzed 88 patients (IED: 36/88, 40.9%; CMT: 52/88, 59.1%) presenting with lumbar central spinal stenosis between 2018–2020. Surgery-related (operation time, complications, time to hospital release (THR), ASA score, C-reactive protein (CRP), white blood cell count (WBC), side (unilateral/bilateral), patient-reported (ODI, NRS (leg-, back pain), eQ5D, COMI), and radiological (preoperative dural sack cross-sectional area (DSCA), Shizas score (SC), left (LRH) and right (RRH) lateral recess heights, left (LFA) and right (RFA) facet angle) parameters were extracted. Complication (most often re-stenosis due to hematoma and/or residual sensorimotor deficits) rates were higher in the endoscopic (38.9%) than microsurgical (13.5%) treatment group (p<0.01). Age, THR, SC, CRP, and DSCA revealed significant correlations with 3 weeks and 1 year postoperatively evaluated ODI, COMI, eQ5D, NRS leg, or NRS back values in our cohort. We did not observe significant differences in the endoscopic versus microsurgical group for the patient-reported outcomes. Age, THR, SC, CRP, and DSCA revealed significant correlations with patient-centered outcomes and should be considered in future studies. Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach, although it was associated with higher complication rates in our single-center study experience. This was probably because of the surgeons' lack of experience with this method and the resulting different learning curve compared with the conventional technique

Advisors. PhD J Hartvigsen, PhD P Aagaard, University of Southern Denmark. PhD G Br⊘nfort, Northwestern Health Sciences University, Minneapolis, MN, USA and NIKKB. PhD G Kawchuk, Canada Research Chair in Spinal Function, University of Edmonton, Alberta, Canada. PhD A Breen, Institute for muscoloskeletal research & clinical implementation, Bournemouth, England. PhD J Rasmussen, Institut for Maskinteknik og Anybody Group, Aalborg Universitet. Introduction. The overall issue of this project is to investigate the relationship between the lumbar spinal biomechanics, patient's pain and physiological effects of traditional conservative treatments. Background. Biomechanical factors such as ranges, patterns and quality of motion in the lumbar spine are thought to be important contributors to many varieties of LBP. Furthermore, commonly used treatments for spine pain such as exercises, training, and various manual treatments such as manipulation are thought to alter biomechanical factors and thereby facilitating return to “normal” function and thus a pain free state. Method. A systematic critical literature review in order to determine the current reproducibility level for measuring 3D regional lumbar spinal motion with various methods and based on the review propose an agenda for future research. Develop of a model to analyze the dynamic non-invasive computerized regional motion data. In this model the complex motion data will be reduced to a manageable size with each movement parameter consisting of individual figures. The data reduction will be done in a developed MATLAB program and the analysis of the reduced data will be handled in STATA. Use collected data from randomized clinical trials (research center at Northwestern Health Sciences University in Minnesota, USA) on the developed model in a reproducibility study and an intervention study

Objective To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion. Method 60 patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of the operation at the end of the procedure. VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively independently. The total dose of morphine required was recorded. Results The patients randomised to receive fentanyl showed a decrease in their mean VAS scores as well as a 40% reduction in the total morphine dose delivered. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment. All patients left recovery after 2 hours to be nursed on an open ward. Conclusion Intrathecal fentanyl is effective at reducing mean pain VAS scores and morphine use via a PCA after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward

Introduction and Aims: To assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing spinal surgery. Method: Sixty patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of operation at the end of the procedure. VAS pain scores were then taken at two, four, 24 and 48 hours post-operatively. Time to first bolus delivery of morphine from the PCA was also recorded, as was the total dose of morphine required. Results: The patients randomised to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine, as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only two patients required HDU observation overnight. The rest of the cohort left recovery after two hours to be nursed in an open ward. Conclusion: Intrathecal Fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients in the open ward

Objective: To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion. Morphine has been shown to be effective intrathecally in spinal surgery but there is an increased incidence of respiratory complications. Fentanyl has not been formally evaluated in this setting. Design: This was a prospective randomized double blind trial. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomized to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of operation at the end of the procedure. Subjects: 30 patients undergoing lumbar spinal surgery were prospectively recruited. Outcome measures: VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively. Time to first bolus delivery of morphine from the PCA was also recorded as was the total dose of morphine required. Results: The patients randomized to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only 2 patients required HDU observation overnight. The rest of the cohort left recovery after 2 hours to be nursed on an open ward. Conclusion: Intrathecal fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward

Study Design: Prospective randomized double blind trial. Objective: To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion. Summary of Background Data: Morphine has been shown to be effective intrathecally in spinal surgery but there is an increased incidence of respiratory complications. Fentanyl has not been formally evaluated in this setting. Methods: All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon under direct vision one or two levels above the site of operation at the end of the procedure. Subjects: 30 patients undergoing lumbar spinal surgery were prospectively recruited. Outcome measures: VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively. Time to first bolus delivery of morphine from the PCA was also recorded as was the total dose of morphine required. Results: The patients randomized to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only two patients required HDU observation overnight. The remainder of the cohort left recovery after 2 hours to be nursed on an open ward. Conclusion: Intrathecal fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward

INTRODUCTION: No previous cases of avascular necrosis (AVN) of the femoral head have been described in the World Literature, to our knowledge. This paper reports the catastrophic failure of the bony integrity of the hip in three patients (five hips) following prolonged hypotension during spinal surgery for spinal stenosis on a Montreal mattress and offers advice to prevent this complication of spinal surgery. A theory to explain this phenomenon is explored, but we recognise its limitations with such a small sample. METHOD: The case notes of all patients undergoing decompressive spinal surgery in our hospitals between March 1997 and December 2001 were examined (168 cases). Three patients had been identified as suffering from AVN following prolonged hypotensive anaesthesia prospectively. No other cases were identified after the notes review. Clinical notes and pre- and post-operative radiographs were studied in an attempt to identify the factors that caused this complication in these three patients. RESULTS: Between 1997 and 2001, 168 patients underwent surgery for multi-level symptomatic spinal stenosis in our hospitals. Forty percent of the patients had an instrumented fusion as well as a decompression. During this period, three patients had catastrophic AVN of the femoral head requiring total hip arthroplasty soon after their spinal operation. All had some clinical and radiological evidence of hip arthritis at their pre-surgery visit. All subsequently, presented with symptomatic hip AVN within six months of the index operation. In two, histology confirmed the diagnosis of AVN, and typical changes of AVN were well demonstrated on MRI in the third patient. CONCLUSIONS: The development of avascular necrosis of the femoral heads following surgery for spinal stenosis may be due to a femoral head at risk being exposed to hypotensive anaesthesia, prone positioning on a Montreal mattress or a combination of the two. Careful intra-operative positioning may reduce the risk of this occurring after spinal surgery. However, close post-operative surveillance and a high index of suspicion of worsening hip pathology in patients who appear to mobilise poorly after lumbar spinal surgery may be the only method of early detection of this condition

Introduction: No previous cases of avascular necrosis (AVN) of the femoral head have been described in the World Literature, to our knowledge. This paper reports the catastrophic failure of the bony integrity of the hip in three patients (five hips) following prolonged hypotension during spinal surgery for spinal stenosis on a Montreal mattress and offers advice to prevent this complication of spinal surgery. A theory to explain this phenomenon is explored, but we recognize its limitations with such a small sample. Method: The case notes of all patients undergoing decompressive spinal surgery in our hospitals between March 1997 and December 2001 were examined (168 cases). Three patients had been identified as suffering from AVN following prolonged hypotensive anaesthesia prospectively. No other cases were identified after the notes review. Clinical notes and pre- and post-operative radiographs were studied in an attempt to identify the factors that caused this complication in these three patients. Results: Between 1997 and 2001, 168 patients underwent surgery for multi-level symptomatic spinal stenosis in our hospitals. Forty percent of the patients had an instrumented fusion as well as a decompression. During this period, three patients had catastrophic AVN of the femoral head requiring total hip arthroplasty soon after their spinal operation. All had some clinical and radiological evidence of hip arthritis at their pre-surgery visit. All subsequently, presented within symptomatic hip AVN within six months of the index operation. In two, histology confirmed the diagnosis of AVN, and typical changes of AVN were well demonstrated on MRI in the third patient. Conclusions: The development of avascular necrosis of the femoral heads following surgery for spinal stenosis may be due to a femoral head at risk being exposed to hypotensive anesthesia, prone positioning on a Montreal mattress or a combination of the two. Careful intra-operative positioning may reduce the risk of this occurring after spinal surgery. However, close post-operative surveillance and a high index of suspicion of worsening hip pathology in patients who appear to mobilize poorly after lumbar spinal surgery may be the only method of early detection of this condition

Biopsies of lumbar multifidus muscles were obtained at operation on seventeen patients aged from fifteen to fifty-eight with lumbar spinal derangement, and further material was taken from the cadavers of three subjects aged from nineteen to fifty-one. Sections were prepared to show the presence of ATPase activity, so distinguishing Fast from Slow types of muscle fibre. The normal mosaic pattern arising from the intermingling of fibres from Fast and Slow motor units was seen in sections from cadaveric material and from many of the biopsies. With age and limited lumbar flexibility, the Fast fibres became relatively smaller but with increasing variation in size, suggesting a reduced capacity for phasic activity. The presence of positive root signs was associated with a greater proportion of Slow fibres, and in some patients with the occurrence of atrophied Fast fibres, giving rise to differences in the populations of the two fibres in neighbouring fascicles. The results suggest that multifidus adopts an increasingly postural role with advancing age and with disabling lesions of the lumbar spine

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used. Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect. A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures

To evaluate the effect of wait time to surgery on patient derived generic and disease-specific functional outcome following lumbar surgery. Study cohort of seventy patients undergoing elective posterior lumbar spinal surgery for degenerative conditions. Prospectively collected SF-36 and Oswestry Disability questionnaires administered preoperatively, six weeks, six months, one year postoperatively. Time intervals from onset of symptoms to initial consultation by family physician through investigations, spinal surgical consultation and time spent on the surgical waiting list to surgery quantified. Time intervals compared to patient-specific improvements in reported outcome following surgery using Cox-Regression analysis. The effect of patient and surgical parameters on wait time was evaluated using median time as a reference for patients with either a longer or shorter wait. Patient follow-up completed in fifty-three (76%). Improvements in patient derived outcome were observed comparing post-operative to pre-operative baseline scores (p< 0.05). The greatest improvements were observed in aspects relating to physical function and pain. A longer wait to surgery was associated with less improvement in surgical outcome (p< 0.05, SF-36 domains BP, GH, RP, VT, and Physical Component Scores). The greatest impact observed was a prolonged surgical wait-list time on SF-36 PCS scores following surgery (Hazard’s ratio 3.53). Patients requiring spinal fusion had a longer wait when compared to those not requiring fusion (p< 0.05). A longer wait time to spinal surgery can negatively influence surgical results as quantified by patient derived functional outcome measures. Surgery resulted in the greatest improvement in pain severity and physical aspects of function, however, these areas also appeared the most impacted by a longer wait to surgery

Objective: This is a prospective, randomised, double blind trial to assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing lumbar spine surgery. Method: 60 patients were recruited. All received our standard analgesic regime with morphine PCA via a syringe driver. They were electronically randomised to two groups – one received 15 micrograms of fentanyl intathecally; the other had nothing. The fentanyl was administered by the operating surgeon under direct vision at the end of the procedure. All patients were monitored in recovery for two hours. Visual Analogue Scale (VAS) pain scores were assessed at 2, 4, 24 and 48 hours post-op. The time to first bolus delivery of PCA was recorded as was the total amount of morphine PCA used. Both patient and assessor were blinded. Results: The patients randomised to receive fentanyl showed a significant decrease in their mean VAS pain scores for the first 24 hours. Their time to first bolus of PCA was significantly increased. They also used 40% less morphine PCA (p< 0.05 in all cases). None of the patients suffered respiratory compromise requiring treatment and they all left recovery after 2 hours to be nursed on the general ward. Conclusion: Intrathecal fentanyl is effective at reducing post-operative pain and PCA morphine use after lumbar spinal surgery. We support its use over morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on a general ward

Hypothesis. Athletes significantly alter their lumbar spinal motion when performing squat lifting at heavy weights. This altered motion effects a change in pressure in the posterior annulus of lumbar discs. Methods. 48 athletes performed 6 lifts at 40% maximum, 4 lifts at 60% maximum and 2 lifts at 80% maximum. Zebris 3-D motion analysis system used to measure lumbar spine motion. Exercise then repeated with weight lifting support belt. 4 cadaveric sheep spinal motion segments fixed to tension/compression loading frame, allowing compression replicating the forces seen in in vivo study. Pressure measurement achieved using a Flexiforce single element force sensor strip, positioned at posterior annulus. Posterior annulus pressure measured during axial compression and on compression with specimen fixed at 3° of extension. Results. Significant decrease (p<0.05) seen in flexion in all groups studied when lifting at 40% maximum was compared with lifting at 60% and 80% of maximum lift. Extension from a calibrated zero point ranged in groups studied from -1.5° (40% group), to -20.3° (80% group). No statistically significant difference found between motion seen when performing exercise as ‘free’ squat or when lifting using support belt in any group. Comparing axially loaded specimens with specimens loaded in extension, there was an average increase in pressure of 36.4% in the posterior annulus, when the spine was loaded in 3° of extension at a pressure equivalent to the 80% lift in the in vivo motion study, in comparison to axial loading. Conclusions. Squat weight lifting at heavier weights, causes athletes to lift at a progressively greater degree of extension. The use of a weight lifting support belt does not significantly alter spinal motion during lifting. The increased extension at heavier weights results in a stress concentration in the posterior annulus

Abstract

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time.¹ Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis.^1,2 There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis.

The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm² at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up.

In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery.³ However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results.

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery.

Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test.

A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point.

In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases.