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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_15 | Pages 37 - 37
7 Aug 2024
Wilson M Cole A Hewson D Hind D Hawksworth O Hyslop M Keetharuth A Macfarlane A Martin B McLeod G Rombach I Swaby L Tripathi S Wilby M
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Background

Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques.

Methods

PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios.


Purpose

To observe the safety and efficacy of a minimally destructive decompressive technique without fusion in patients with lumbar stenosis secondary to degenerative spondylolisthesis.

Methods

30 patients with degenerative spondylolisthesis (DS) were consecutively managed by a single consultant spinal surgeon. All patients presented with neurogenic claudication secondary to DS. All patients were managed operatively with lumbar decompression utilising an approach technique of “spinous process osteotomy” (1). Briefly, this approach requires only unilateral muscle stripping with preservation of the interspinous ligament. A standard centrolateral decompression is then performed. Data consisting of VAS back and leg pain and ODI were collected pre and post-operatively.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 122 - 122
1 Apr 2012
Slator N Wilby M Tsegaye M
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To audit patient satisfaction throughout the perioperative period amongst emergency and elective admissions in the spinal team.

92 patients were identified whom underwent operations within a 3 month period using the operating database. A self administered postal questionnaire was sent to assess preoperative waiting time, quality of preoperative assessment and information given, assessment of their admission, their experience throughout hospital stay and the quality of their post operative assessment and discharge.

Patient reported outcomes (PROMS)

Response rate 35% (32/92) of which 24 (14F 10M) were elective admissions and 8 emergency admissions (2F 6M). Average wait for elective procedure was 5.7 weeks (median 2).

63% of elective patients were seen in prescreening clinic and 79% of these received an information booklet prior to operation.

22% of patients had delayed discharge due to non clinical causes including awaiting transport, awaiting medications and physiotherapy clearance.

88% of patients reported they were given adequate information regarding post-operative daily activities.

79% of elective patients reported seeing a doctor on the day of their discharge however only 38% reported seeing a physiotherapist postoperatively. This fell to 0% for patients operated on a Friday.

Although 94% of patients reported that they were satisfied with the overall care they were given, they reported certain aspects of their clinical care being less than optimal.

Trust wide assessment of patient reported outcomes to assess and improve the quality of care against national guidelines.

Ethics Approval: Self questionnaire approved by ethics committee


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 438 - 438
1 Sep 2009
Wilby M Vernon-Roberts B Fraser R Moore R
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Introduction: Thickened ligamentum flavum (LF) is a major contributor to the clinical syndrome of lumbar canal stenosis (LCS). The patho-mechanisms responsible for this phenomenon remain unclear. Cysts adjacent to facet joints (FJ) in the spine are regarded as rare entities that may uncommonly contribute to LCS. Inaccurate pathological interpretation and unawareness of a key anatomical feature has generated erratic terminology and confusion about their origin.

Methods: Twenty-seven consecutive patients with radiologically confirmed central canal or lateral recess stenosis underwent lumbar laminectomy for neurogenic symptoms. Surgical specimens comprising en bloc excision of LF and medial inferior facet (to retain LF and FJ relationships) were examined microscopically following staining with haematoxylin-eosin and Miller’s elastic stain. Controls were facet/LF specimens from 89 cadaver lumbar spines.

Results: Mean LF thickness was 8.9 mm (+/− 0.3 mm SEM) at the operated levels and 2.9 mm (+/− 0.3 mm) at the non-operated, adjacent levels (p < 0.01). Twenty-eight synovial cysts (8 bilateral, 12 unilateral) were present at a single level in 20 (74%) patients. Synovial cysts per spine level were: L1/2 = 0; L2/3 = 3; L3/4 = 7; L4/5 = 16; L5/S1 = 2. The cyst levels all showed advanced osteoarthritis and LF degeneration. Ten patients (50 %) with cysts had pre-existing degenerative spondylolisthesis (DS). Only 5 patients had pre-operative radiological apperances of unilateral facet cysts. Therefore 82 % of our observed synovial cysts were microscopic or occult. The synovial cysts communicated with the FJ via a bursa-like cleft within the LF, and their linings of synoviocytes and other cells contained fragments shed from the articular surface. The control cadaver specimens revealed that a synovial bursa or intra-ligamentous out-pouching from the synovial cavity was present in 90% of normal LF at L4/5 and was up to 12 mm in length. This intra-ligamentous synovial recess, either wholly or partially lined by synoviocytes, was only present in 55% of specimens at L1/2 with a maximum length of 5 mm. Several other juxtafacet cyst types were observed in the experimental group and a novel classification based upon pathological findings is presented.

Discussion: Para-facetal intraspinal cysts are common in degenerative lumbar spinal stenosis. DS is also a frequent finding but is statistically unrelated to cyst formation (Chi-square: p=0.187). We have found that debris from osteoarthritic facet joints enters a bursa-like cleft within the LF where it becomes incorporated into the wall where it excites a granulomatous reaction leading to blockage and synovial cyst formation. The existence of this channel has not been reported previously. We suggest that microscopic synovial cysts contribute significantly to the ligamentous thickening seen in LCS. We also present a novel classification of juxtafacet cysts based on our pathological findings.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 438 - 438
1 Sep 2009
Ardern D Callary S Wilby M Christensen B Vernon-Roberts B Fraser R Moore R
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Introduction: Spondylolysis in skeletally immature individuals is common but only a small proportion of cases develop pain and spondylolisthesis. The pattern of instability and pathologic consequences of surgically created spondylolytic defects have not previously been described. An animal model of lumbar spondylolysis was created using skeletally immature sheep with the aim of observing the intervertebral mobility and pathologic consequences of creating a spondylolytic segment.

Methods: Bilateral spondylolytic defects were created in the fifth lumbar vertebrae of fourteen sheep aged approximately 16 weeks using a posterior surgical approach. Using tantalum markers that were placed in the lumbar spine segments in the vicinity of the lesion, three dimensional translations and rotations in flexion and extension were recorded under general anaesthetic using Radiostereometric Analysis (RSA) at the time of surgery. A novel method of ovine spine manipulation was developed. Briefly, with the animal in a lateral decubitus position spinal extension was achieved by fixing the shoulders and hips in full extension. Similarly, the limbs were brought into apposition to achieve spinal flexion. A control group of seven sheep had tantalum markers only in the same lumbar spine segments. The animals were re-tested under general anaesthetic at six weeks and six months following surgery. After six months the animals were sacrificed and their spines examined using CT and microscopic analysis.

Results: Bilateral spondylolytic defects did not result in significant transverse (x-axis) translation. RSA showed significant differences between the spondylolytic group (mean 1.22°, range 0.30–3.74) and controls (mean 0.28°, range 0.03–0.77)) for rotation in the axial plane (y-axis, p< 0.0025) immediately after surgery. The spines radiologically stabilised over six months.

Discussion: Surgically induced bilateral spondylolytic defects in this immature ovine model result in increased rotation in the axial plane but do not create transverse translation (spondylolisthesis).


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 457 - 457
1 Aug 2008
Mannion R Wilby M Godward S Laing R
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Study purpose: Cancer patients presenting with symptomatic spinal metastases is an increasing problem. It is widely accepted that surgery plays an important role in the management of these patients and recent studies1 conclude that surgical treatment should be more frequently offered. However, who should be offered surgery remains controversial, largely because of a lack of information about outcome. Our study is a prospective analysis of survival and functional outcome in patients with metastatic spinal disease treated primarily by surgical decompression and stabilisation when indicated.

Methods: Sixty two patients with radiologically suspected metastatic spinal disease, managed by one consultant neurosurgeon, were enrolled into a prospective cohort study. Patients presented with pain and or myelopathy. Survival, continence, walking, analogue pain scores and short form 36 (SF-36) scores were analysed.

Results: Median age was 62 years (22–79 years, 35 female, 27 male) with the commonest primary tumours being breast (26%), lymphoma (13%) and prostate (10%). Lung cancer was poorly represented (1 patient). Survival rates were 56% at 1 year, 49% at 2 years and 28% at 3 years. Of 16 patients not walking pre-op, 8 gained the ability to walk, while 5 out of 7 incontinent patients gained continence following surgery.

Conclusion: Our data indicate that long term survival and favourable functional outcomes can be achieved following surgery in patients with metastatic spinal disease. We strongly advocate that patients presenting with metastatic spinal disease be considered for primary surgical treatment but would highlight the importance of appropriate patient selection.