Approximately 20-25% of patients having joint replacement in the UK have moderate-severe frailty. Frailty is associated with poorer outcomes after joint replacement. Targeting frailty pre-operatively with exercise and protein supplementation could improve post-operative outcomes. Prior to conducting a randomised controlled trial (RCT), a feasibility study was necessary to inform trial design and delivery. We conducted a randomised feasibility study with embedded qualitative work. Patients aged ≥65 years, frail and undergoing THR or TKR were recruited from three UK hospitals. Participants were randomly allocated on a 1:1 ratio to the intervention or usual care group. The intervention group had a 1:1 appointment with a physiotherapist and were provided with a home-based, tailored daily exercise programme and a daily protein supplement for 12 weeks before their operation, supported by six telephone calls from a physiotherapist. Questionnaires were administered at baseline and 12 weeks after randomisation. Interviews were conducted with 19 patients. Feasibility outcomes were eligibility and recruitment rates, intervention adherence, and acceptability of the trial and the intervention.Introduction
Method
The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA). Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey.Aims
Methods
There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR. REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.Abstract
Introduction
Methodology
Approximately 15–20% of patients report chronic pain three months after total knee replacement (TKR). The STAR care pathway is a clinically important and cost-effective personalised intervention for patients with pain 3 months after TKR. The pathway comprises screening, assesment, onward referral for treatment and follow-up over one year. In a multicentre randomised controlled trial comparing the pathway with usual care, the pathway improved pain at 6 and 12 months. This study examined the longer-term clinical and cost-effectiveness of the STAR care pathway. STAR trial participants were followed-up at a median of 4 years post-randomisation. Co-primary outcomes were self-reported pain severity and interference in the replaced knee, assessed with the Brief Pain Inventory (BPI). Resource use from electronic hospital records was valued with UK reference costs.Abstract
Introduction
Methodology
Total knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR. The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs). There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation. Trial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were contacted to understand their capacity to implement the intervention locally.Abstract
Introduction
Methodology
Frailty is associated with poorer outcomes after joint replacement. Targeting frailty pre-operatively via protein supplementation and exercise has the potential to improve outcomes after joint replacement. Before conducting a randomised controlled trial (RCT), a feasibility study is necessary to address key uncertainties and explore how to optimise trial design. Joint PREP is a feasibility study for a multicentre, two-arm, parallel group, pragmatic, RCT to evaluate the clinical and cost-effectiveness of prehabilitation for frail patients undergoing total hip or knee replacement. Sixty people who are ≥65 years of age, frail and scheduled to undergo total hip or knee replacement at 2–3 NHS hospitals will be recruited and randomly allocated on a 1:1 ratio to the intervention or usual care group. The intervention group will be given a daily protein supplement and will be asked to follow a home-based, tailored daily exercise programme for 12 weeks before their operation, supported by fortnightly telephone calls from a physiotherapist. Embedded qualitative research with patients will explore their experiences of participating, reasons for non-participation and/or reasons for withdrawal or treatment discontinuation.Abstract
Introduction
Methodology
Total knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics. We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR. Between 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4).Abstract
Introduction
Methodology
Outcome after traumatic spinal fracture is difficult to predict. Some patients have ongoing pain while others make a good recovery and there is therefore considerable debate as to which fractures should be treated operatively. Delayed operations for ongoing pain post fracture are more expensive with a longer recovery. The sagittal balance of the spine may predict patient outcomes post fracture. Identify subjects with stable spine fractures not requiring acute fixation and compare their sagittal parameters measured on initial standing x-ray with whether or not they have ongoing pain.Background:
Aim:
To identify the most cited British author, unit and country within Great Britain among the scoliosis and spinal deformity literature. Using methods as described by Skovrlj (2014), a search of the Thomson Reuters Web of Science was performed using the terms ‘scoliosis’ and ‘spine deformity’ from 1900 to 2013 published from authors in the following countries: UK, England, Scotland, Ireland, Wales. Additional citations searches were performed using PubMed and Google scholar. Results were sorted according to number of citations; papers applicable to scoliosis or spinal deformity were chosen. The Top 25 citations from British authors were established. 80% of papers were published before 2000. Citation counts and therefore rankings varied for each of the three citation searches, producing differences in rank of as great as 28 for the same paper. Ruth Wynne-Davies from Edinburgh ranked number one in all three searches, followed by SG Boyd, R Dickson, and M McMaster. Half of the top ten papers were published by authors from Edinburgh. The most cited author in Great Britain from all citation searches is Ruth Wynne Davies. However, the citation count of all papers varied depending on the search platform used, producing varying ranks for all other papers.
Modern techniques facilitate the treatment of adult spinal deformity. Decision making is a challenge because of potential complications relating to the surgery itself and medical problems. This study aims to provide useful data in facilitating the decision making process. Retrospective analysis of consecutive single surgeon series of patients aged >50 between 2006-2009 undergoing multi-level spinal deformity surgery with concomitant decompression. Medical co-morbidities, age and ASA were recorded. 71 patients (57 female) mean age 66 (50-83). 29 (12 multiple) failed previous stenosis surgery. 14(19.7%) in hospital complications in 11(15.5%) patients. 4 were ‘medical’. 8/11 patients were revision cases versus 3/11 primary. 4 patients (5.6%) needed further surgery. 13(18.3%) outpatient complications in 12(16.9%)patients. 7/12 occurred in revision cases versus 5/12 in primary. 11(15.5%) needed further surgery. Revisional surgery in adult deformity presents a significantly higher overall complication rate than primary surgery (p= 0.0084), but both revisional and primary cases have a relatively high re-operation rate once initially discharged. The results indicate that complex medical and surgical factors contribute to the decision making challenge in patients with adult spinal deformity and stenosis.
Lumbar myelography was a commonly performed procedure but was superseded by MRI and CT which were low risk and provided cross-sectional information. The majority of MRI and CT evaluations are static and supine whereas myelography may be loaded and dynamic. This study evaluates the role of myelography in patients with degenerative scoliosis in a modern surgical practice. Patients with degenerative scoliosis and full imaging (plain radiographs, supine MRI, myelography, including CT myelography) were identified from our database between 2006-2009. Differences between findings of MRI and myelography/CT myelography were noted and whether this subsequently affected treatment. 21 patients fulfilled inclusion criteria. Mean age 68 (45-82), 17 females. 18/21(85.7%) myelograms revealed findings not seen on MRI. 15 patients had a single abnormality, 1 had two and in 2 patients there were 3 new abnormalities. These were facet/ligamentous bulging in 13, a single spondylolisthesis, retrolisthesis and lateral subluxation. On CT a foraminal osteophyte and a pars defect were seen. In 4 cases supine investigation revealed more than MRI. In 7 patients management changed as a result of myelography/CT. There have been no complications of myelography in our unit of the total 270 performed. Myelography is a safe and useful tool in the management of patients with degenerative scoliosis. MRI scan alone understates the true nature of central and lateral recess stenosis. Not only does myelography show more stenosis in the loaded spine, but static myelography and CT myelography are also an invaluable tool in these patients.
Post traumatic stress disorder (PTSD) is well recognised in children having repeated medical/surgical procedures. It has been suggested that it is common in young children undergoing growing rod treatment with ongoing lengthening and the inevitable accompanying complications. We present an index case history, review the literature in order to infer a correlation for the incidence of PTSD and discuss diagnosis and management. We present an index case history of PTSD in a young child undergoing growing rod treatment for scoliosis. The literature was reviewed for PTSD in paediatric surgery and pathologies requiring multiple treatments. Spinal surgery is compared with paediatric cancer, burns, organ failure/transplant, cardiopulmonary disease, inflammatory bowel disease, cystic fibrosis and limb lengthening. No published studies examine PTSD in children undergoing multiple spinal surgeries. One paper reports that children undergoing growing rod treatments show “behavioural alterations” and changes in psychosocial behaviour, including anxiety on entering the operating room and broken rod worries. A recent spine meeting presentation referred to this. Psychosocial problems occur in up to 30% of children with chronic or life-threatening illnesses which involve ongoing treatments. Factors such as age, parental anxiety and previous adverse medical experiences influence anxiety, depression and PTSD. Based on our index case and methodological correlation with similar pathologies, we fell that PTSD is a genuine concern in children who have repeated spinal operations. This paper is part of an ongoing study, but we believe that the spinal community should be aware of this diagnosis and its management. Ethics approval: Audit Interest Statement: None
Traditionally, spinal surgeons placed radiographs on viewing boxes in a manner (PA) to replicate the view they would have at surgery. The introduction of digital Picture Archiving and Communications System (PACS) appears to have had marked impact upon this convention. Some Units have the ability to lock digital radiographs such that they are always viewed in the same manner and cannot be reversed. Following ‘two near misses’ we carried out a survey to confirm the previous practice with radiographs; to ascertain the current practice with PACS and to find out whether the variation in practice could lead to clinical mishaps and harm to patients. Questionnaires were completed by practicing spinal surgeons. Previous and current practice of viewing radiographs. Either actual or potential wrong side surgery. Opinions as to whether a single convention was important were recorded. 78 % Spine surgeons used to flip radiographs over prior to introduction of PACS. With PACS, 56 % spine surgeons flip the radiographs over in clinic and 72 % in theatre so to resemble viewing spine from behind. 56% Surgeons had nearly operated on the wrong side of the spine while 94 % have seen or heard of a patient operated on the wrong side. 72 % Spine surgeons agree that the radiographs should be flipped over so as to resemble the spine as viewed intraoperatively. There is need for a single convention in spine surgery to view radiographs to avoid potential clinical mistakes.
Auckland City Hospital, Auckland, New Zealand. To show that the spinous processes (SPs) increase in size with age. To investigate the incidence of SP abutment, relationship to disc degeneration and age related kyphosis. Describe patterns of SP neoarticulation in relation to back pain and intersegmental axial rotation and deformity. We reviewed 200 Abdominal CTs, CT myelograms and 100 standing x-rays (age 18-90 years). We measured SP size, interspinous gap, patterns of neoarticulation, disc height, lumbar lordosis and axial rotation. We compared symptomatic and asymptomatic groups. A 30-50% increase in SP size coupled combined with a loss of disc height leads to increasing rates of SP abutment after the age of 35 years. 30% of people over the age of 60 years have SP abutment. There is a 15 degree increase in standing lumbar kyphosis with age. Four patterns of SP neoarticulation are seen. Degenerative changes in the SP articulation increase by more than 80% in a symptomatic cohort. Oblique SP articulation is 2.5 times more likely in symptomatic individuals and associated with a rotational intersegmental deformity. Ageing is accompanied by SP enlargement and abutment, contributing to a loss of lumbar lordosis. Patterns of neoarticulation and degeneration appear associated with back pain and rotational deformity.
The main objective of our review was to access the inter-net websites providing information on non operative treatment of scoliosis and to assess the evidence for each treatment in the medical literature.
These treatments were then entered for search in Medline and Embase, only 45% (9/20) of these treatments were found to have been described in the medical literature.
