The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane.

To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level.

Retrospective Study

200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane.

The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%).

As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity.

Spinal deformations are posture dependent. Official data from the Netherlands show that youth are encountering increasing problems with the musculoskeletal system (>40% back pain, and sport injury proneness). Prolonged sloth and slumped sitting postures are causative factors. Dutch youth are “champion sitting” in Europe. The effects of sitting on the development of posture and function of locomotion (stiffness) during growth have only been reported clearly in classic textbooks (in German) of practical anatomy and orthopaedics. Research with relevant clinical examinations is being done to understand epidemiological data on the increasing posture-dependent problems. A cohort of adolescents (15–18 years) in secondary school was assessed for sagittal postural deviations while bending. 248 children completed a questionnaire, and tests were done on neuromuscular tightness. The femorotibial angle was used to measure hamstring tightness. Measurement of the dorsiflexion of the foot was used to assess the tightness of calf muscles and Achilles tendons. All adolescents were photographed laterally while performing the finger–floor test (used to test flexibility), assessed as a knockout test: “Can you reach the floor or not?” The spinal profiles while bending were classified as abnormal arcuate or angular kyphosis. Hamstring tightness was present in 62.1% of the cohort in both legs, and in 18.2% unilaterally. Achilles tendon tightness was present bilaterally in 59.3%, and unilaterally in 19.4%. Activities with presence of stiffness (finger–floor distance), in descending order, were football, running, no sports, field hockey, tennis, dance, and gymnastics. 93.5% of the soccer players had tight hamstrings in both legs compared with none of those performing gymnastics. The correlation of the finger–floor test with tight hamstrings was 73.2%. For sagittal bending deformities, the correlation between form and function deficits cannot be made yet. 80 of 248 spines were rated by the examiners as having deformed flexion. Since Andry (1741) and at the zenith of continental orthopaedics and anatomy around 1900, the prolonged flexed positions of a young spine were indicated as being the main cause of deformity by overload and shear loads on immature discs and cartilage, preventing normal development of the discs. Nachemson proved that the intradiscal pressure in sitting adults was extremely high, so it follows that children must also be at risk. Evidence suggests that youth, generally because of their sedentary and “screenful lifestyle”, will encounter serious problems in growth, manifesting as incongruent neuro-osseous growth (Roth), serious neuromuscular tightness (being prone to injury), and spinal deformations, leading to pain

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS. AP. ) and mediolateral (MoS. ML. ) directions in girls with AIS to Controls. Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS. AP/ML. was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS. AP/ML. between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05. A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS. AP. was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS. ML. , but there was a visual trend for a smaller MoS. ML. in Cases. There was no significant difference for speed or the interaction between group and speed for MoS. AP. or MoS. ML. In Cases, MoS. AP. increased with increasing Cobb angle on the left (r. 2. =0.687, p=0.054) and right (r. 2. =0.634, p=0.067) and MoS. ML. decreased with increasing Cobb angle on the left (r. 2. =-0.912, p=0.002). Further subjects are being recruited. Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types

Introduction. Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone. Planning Methodology. First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies. Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken. Results. Patient rehabilitated well and was discharged after 42 days. Patient underwent SABR two months post-operatively. Despite left foot drop, she was walking independently 9 months post-operatively. Conclusion. These challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR for maximum local control

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

Aims

To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation.

Background. Gore and Nadkarni described a ‘Gore sign’ of reproducing radiating leg pain by palpation of distal nerve root endings in the foot for L5 and S1 nerve roots in lumbar radiculopathy due to disc prolapse. Purpose. This sign was explored and observation of symptoms recorded. Results. There were 31 patients, 20 females and 11 males, aged 25 to 76 years. 13 patients had acute disc prolapse, 14 had lumbar canal stenosis, 3 had annular tears and one had a facet cyst. Radiating leg pain was reproduced in all patients by palpation of distal nerve root endings and was immediately relieved by local anaesthetic injection around distal nerve root endings in all patients (second part of Gore test). New clinical signs were observed which have not been described before:. Back pain was reproduced in 21 patients. L4 nerve root pain was reproduced in 13 patients by palpation of the proximal tibia. Crossed leg pain was reproduced in 5 patients. Reproduction of pain by palpation of more than one distal nerve root ending was observed in 16 patients. Cessation of radiating leg pain by palpation of distal nerve root endings in two patients. These test were positive in patients with varied pathology producing radiculopathy, not just disc prolapse. Conclusion. Provocative nerve root tension signs can be difficult in severe pain. The tests described above can be performed without having to move the patient's lower limb. These observations open up discussion on the mechanism of radiculopathy and new ways of treatment. Conflicts of interest: None. Sources of funding: None

Background and purpose of the study. Axial Spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5- 8 years with impacts on effective and timely management, outcomes and quality of life. NICE Guidance (2017) highlights the importance of the recognition and referral of suspected axial spondyloarthritis. This study investigated the occurrence of physiotherapy care prior to diagnosis of axSpA within physiotherapy outpatient settings. Methods and results. A retrospective review was performed of all patients diagnosed with axSpA who had received physiotherapy care prior to their diagnosis from 1990–2016. Three or more episodes of care prior to diagnosis was taken as unrecognised axSpA. Information was obtained on diagnostic codes, number of episodes of care and contacts per episode from nine outpatient physiotherapy services. Analysis showed that 263 people (17–69 years) diagnosed with axSpAs had received physiotherapy care prior to diagnosis. Within this population, 103 (44%) had received ≥3 episodes of care. Number of contacts within each episode ranged from 3 (47 people) to 58 (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy episode to date of diagnosis was 6.4 years (range=0.3–12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Conclusion. Findings illustrate the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal physiotherapy practice. It is essential to improve screening and recognition of inflammatory back pain and possible axSpA in musculoskeletal assessments, supported by rheumatology referral guidance. No conflicts of interest. No funding obtained

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Diastematomyelia is a rare congenital abnormality of the spinal cord. This paper summarises more than 30 years’ experience of treating this condition. Data were collected retrospectively on 138 patients with diastematomyelia (34 males, 104 females) who were treated at our hospital from May 1978 to April 2010. A total of 106 patients had double dural tubes (type 1 diastematomyelia), and 32 patients had single dural tubes (type 2 diastematomyelia). Radiographs, CT myelography, and MRI showed characteristic kyphoscoliosis, widening of the interpedicle distance, and bony, cartilaginous, and fibrous septum. The incidences of symptoms including characteristic changes of the dorsal skin, neurological disorders, and congenital spinal or foot deformity were significantly higher in type 1 than in type 2. Surgery is more effective for patients with type 1 diastematomyelia; patients without surgery showed no improvement

Aims

Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy.

Introduction. Low back pain (LBP) is the top leading global cause of years lived with disability. In order to examine LBP, researchers have typically viewed the spine in isolation. Clinically, it is imperative that the lower limbs are also considered. The aim of this study was to design a holistic and reliable multi-segmental kinematic model of the spine and lower limbs. Method. The spine was modelled according to easily identifiable anatomical landmarks, including upper thoracic (T1-T6), lower thoracic (T7-T12) and lumbar (L1-L5) segments. Pelvis, thigh, shank and foot segments were included. A 10-camera 3D motion capture system was used to track retro-reflective markers, which were used to define each segment of 10 healthy participants as they walked 3 times at a comfortable speed over a 6km walkway. The relative peak angles between each segment were calculated using the Joint Coordinate System convention and Intraclass Correlation Coefficients (ICCs) were used to determine intra-rater and inter-rater reliability (between an experienced clinician and biomechanical scientist). Results. Intra-rater and inter-rater ICCs were good to excellent (0.6–0.99). This implies that the system could be used reliably by one tester or by testers with limited anatomical expertise. Subjective participant reports implied that the system was acceptable and suitable for patient use (average application time of 10 minutes). Conclusion. The ‘Imperial Spinal Model’ is a holistic and reliable multi-segmental model. It is suitable for the kinematic assessment of the spine and could be used to enhance our understanding of a variety of spinal conditions. No conflicts of interest. Funding: Janet Deane is funded by an Allied Health Professional Doctoral Fellowship awarded by Arthritis Research U.K. (ARUK). Enrica Papi is funded by the National Centre of Excellence for Musculoskeletal Health and Work funded by ARUK and the Medical Research Council

Aims

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES.

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.

Statement of Purpose. It is well known that individuals with a history of low back pain (hLBP) exhibit altered movement patterns that are caused by changes in neuromuscular control. Postural disturbance provides an effective method for creating these differentiable movement patterns. This study has explored the response of the lower limb and spine to a translational perturbation similar to that experienced on public transport in healthy volunteers and those with hLBP. Methods. Healthy volunteers (n=16) and subjects with hLBP (n=10) were subjected to 31 identical postural disturbances at varying time intervals while standing atop a moving platform. Skeletal kinematics and muscle activation were recorded using a 10-camera Vicon system (Oxford, UK) and Myon electromyography (EMG) at the trunk (lumbar, lower thoracic, and upper thoracic segments), pelvis, thigh, calf, and foot. Joint angles were calculated using Body Builder (Vicon) and a unilateral seven-segment custom model. Results. Examination of the total range of joint motion (RoM) exhibited during the trial demonstrated similar RoM at the knee and hip (p=0.90 and 0.97 respectively), but less RoM for the hLBP group at the ankle and lumbar spine (p=0.21 and 0.38, respectively). EMG signals revealed higher muscle activation of the lower limbs from the hLBP cohort compared to healthy controls, yet greater activation at the gluteal and oblique muscles in the control group. Conclusions. In the presently small cohorts, trends demonstrate that differences in postural strategies exist between the healthy and hLBP cohorts, yet further testing of LBP patients will further clarify targets for rehabilitation

Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery. Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013. 62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r. s. = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r. s. = −0.64; p<0.001) and reduced echo SF (r. s. = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR. Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure

Purpose of Study. To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines. Methods. A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines. Results. Thirty specialised centres were contacted. Twenty eight centres followed NICE recommendations, with 2 centres using their own protocol. Four centres made changes to their existing protocols after the emergence of NICE guidelines. GCS (Graduated compression stockings) were uniformly used by all, with most centres using flowtron boots and/or foot in addition. The practices are differing within centres for elective versus trauma surgery. Of note, in patients with an acute cord injury, 20 centres used combined pre operative prophylaxis whereas 10 centres used only mechanical prophylaxis. Three units (10 %) describe a noticeable rise in complications related to chemoprophylaxis, whilst only one unit has reported a PE death within the last year. Discussion. Our survey assesses compliance to the NICE guidelines by the UK's spinal units. Mechanical prophylaxis appears to be the most common mode of prophylaxis understandably due to predictable safety profile. Use of chemo-prophylaxis varies amongst different surgeons and centres. Rather than a result of evidence based practice, the decision appears to be related to the previous experiences of that unit. Although the NICE guidelines provide a reasonable platform to the practice of thromboprophylaxis, more studies are required to evaluate the risks of thrombosis and bleeding events in spinal surgery

Introduction. The British Scoliosis Society published a document in 2008 which set out the minimum standards for paediatric spinal deformity services to achieve over a period of time. But how do the UK paediatric spinal deformity centres measure up to these benchmarks?. Methods. We performed a telephonic survey, contacting every UK spinal deformity centre. The questionnaire probed how each unit compared to the recommended standards. Results. Twenty three centres were interviewed, covering 81 surgeons in total (range 1-8 surgeons per centre). Four centres (17%) did not have 24-hour access to a MRI scanner and all but 2 centres had on-site facilities for long-cassette films/scoliograms. Five centres (22%) always had 2 consultant surgeons per case, 9 centres (39%) routinely have only 1 consultant surgeon per case, and the rest had 1 or 2 consultant surgeons depending on seniority. Six centres (26%) did not routinely have shared care of their patients with the paediatric team. All centres used intra-operative SSEP monitoring, a minority used MEP monitoring (34%), and all but 2 centres had either direct or indirect supervision by a consultant neurophysiologist. All centres have cell saver units available with over half using them routinely (14/23). None of the centres used routine chemoprophylaxis. All units used thromboembolic stockings, with five centres (22%) routinely using foot pumps. Nineteen centres (83%) routinely sent their spinal deformity patients to ITU/PICU postoperatively. Our survey also asked each center what supporting facilities were available, whether they ran adolescent clinics, and whether they participate in multi-disciplinary meetings and audit. In addition, we questioned what typed of drains each center used and the length of time that patients were followed-up. Conclusion. This survey shows how the UK spinal deformity units stand up against the BSS standards, provides an insight in to current UK practice and highlights areas for improvement

Aims

The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS).

The aim of this study was to evaluate the feasibility of using the intact S1 nerve root as a donor nerve to repair an avulsion of the contralateral lumbosacral plexus. Two cohorts of patients were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients with a unilateral fracture of the sacrum and sacral nerve injury were stimulated during surgery to establish the precise functional distribution of the S1 nerve root and its proportional contribution to individual muscles. In cohort 2, the contralateral uninjured S1 nerve root of six patients with a unilateral lumbosacral plexus avulsion was transected extradurally and used with a 25 cm segment of the common peroneal nerve from the injured leg to reconstruct the avulsed plexus.

The results from cohort 1 showed that the innervation of S1 in each muscle can be compensated for by L4, L5, S2 and S3. Numbness in the toes and a reduction in strength were found after surgery in cohort 2, but these symptoms gradually disappeared and strength recovered. The results of electrophysiological studies of the donor limb were generally normal.

Severing the S1 nerve root does not appear to damage the healthy limb as far as clinical assessment and electrophysiological testing can determine. Consequently, the S1 nerve can be considered to be a suitable donor nerve for reconstruction of an avulsed contralateral lumbosacral plexus.

Cite this article: Bone Joint J 2015; 97-B:358–65.