The failure of subcategorization of cauda equina syndrome.

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. This paper presents a reassessment of the diagnostic and prognostic subcategories of CES the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Exploring the potential of ChatGPT in the peer review process: An observational study.

BACKGROUND: Peer review is the established method for evaluating the quality and validity of research manuscripts in scholarly publishing. However, scientific peer review faces challenges as the volume of submitted research has steadily increased in recent years. Time constraints and peer review quality assurance can place burdens on reviewers, potentially discouraging their participation. Some artificial intelligence (AI) tools might assist in relieving these pressures. This study explores the efficiency and effectiveness of one of the artificial intelligence (AI) chatbots, ChatGPT (Generative Pre-trained Transformer), in the peer review process. METHODS: Twenty-one peer-reviewed research articles were anonymised to ensure unbiased evaluation. Each article was reviewed by two humans and by versions 3.5 and 4.0 of ChatGPT. The AI was instructed to provide three positive and three negative comments on the articles and recommend whether they should be accepted or rejected. The human and AI results were compared using a 5-point Likert scale to determine the level of agreement. The correlation between ChatGPT responses and the acceptance or rejection of the papers was also examined. RESULTS: Subjective review similarity between human reviewers and ChatGPT showed a mean score of 3.6/5 for ChatGPT 3.5 and 3.76/5 for ChatGPT 4.0. The correlation between human and AI review scores was statistically significant for ChatGPT 3.5, but not for ChatGPT 4.0. CONCLUSION: ChatGPT can complement human scientific peer review, enhancing efficiency and promptness in the editorial process. However, a fully automated AI review process is currently not advisable, and ChatGPT's role should be regarded as highly constrained for the present and near future.

Which treatment provides the best neurological outcomes in acute spinal cord injury?

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Home-Based EEG Neurofeedback Intervention for the Management of Chronic Pain.

Background: Chronic pain and associated symptoms often cause significant disability and reduced quality of life (QoL). Neurofeedback (NFB) as part of a Brain Computer Interface can help some patients manage chronic pain by normalising maladaptive brain activity measured with electroencephalography (EEG). Objectives: This study was designed to assess the efficacy and safety of a novel home-based NFB device for managing chronic pain by modifying specific EEG activity. Methods: A prospective, single-arm, proof-of-concept study was conducted between June 2020 and March 2021 among adults with chronic pain (registered with ClinicalTrials.gov NCT04418362). Axon EEG NFB systems for home use were provided to each, and 32-48 NFB training sessions were completed by the participants over 8-weeks. The primary outcome was self-reported pain. Assessment of central sensitisation, sleep quality, affective symptoms, change in QoL, adverse events during use and EEG correlations with symptoms were secondary outcomes. Results: Sixteen participants were enrolled. Eleven reported pain relief following NFB training, eight reporting clinically significant improvements. Central sensitisation symptoms improved by a third (p < 0.0001), sleep quality by almost 50% (p < 0.001), anxiety reduced by 40% (p = 0.015), and QoL improved at final follow-up for 13 participants. The majority (69%) of participants who upregulated relative alpha reported improved pain, and those who downregulated relative hi-beta reported improved pain, reduced anxiety and depression scores. There were no adverse events during the trial. Conclusions: Home-based NFB training is well-tolerated and may provide relief for sufferers of chronic pain and its associated symptoms. Summary: Axon, a home-based NFB training device, can positively influence pain and associated symptoms in a proportion of people with chronic pain.

Cervical transforaminal epidural steroid injections for radicular pain : a systematic review.

AIMS: Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. METHODS: OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. RESULTS: Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. CONCLUSION: There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567-574.

The diagnostic and prognostic value of artificial intelligence and artificial neural networks in spinal surgery : a narrative review.

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442-1448.

The cost of consent: why healthcare providers must be compliant with the Montgomery principles.

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of "failure to warn", i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on "failure to warn" and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550-555.

Surgeon proficiency in robot-assisted spine surgery.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568-572.

Results of the first interim analysis of the RAPPER II trial in patients with spinal cord injury: ambulation and functional exercise programs in the REX powered walking aid.

BACKGROUND: The RAPPER II study investigates the feasibility, safety and acceptability of using the REX self-stabilising robotic exoskeleton in people with spinal cord injury (SCI) who are obligatory wheelchair users. Feasibility is assessed by the completion of transfer into the REX device, competency in achieving autonomous control and completion of upper body exercise in an upright position in the REX device. Safety is measured by the occurrence of serious adverse events. Device acceptability is assessed with a user questionnaire. METHODS: RAPPER II is a prospective, multi-centre, open label, non-randomised, non-comparative cohort study in people with SCI recruited from neurological rehabilitation centres in the United Kingdom, Australia and New Zealand. This is the planned interim report of the first 20 participants. Each completed a transfer into the REX, were trained to achieve machine control and completed Timed Up and Go (TUG) tests as well as upper body exercises in standing in a single first time session. The time to achieve each task as well as the amount of assistance required was recorded. After finishing the trial tasks a User Experience questionnaire, exploring device acceptability, was completed. RESULTS: All participants could transfer into the REX. The mean transfer time was 439 s. Nineteen completed the exercise regime. Eighteen could achieve autonomous control of the REX, 17 of whom needed either no assistance or the help of just one therapist. Eighteen participants completed at least one TUG test in a mean time of 313 s, 15 with the assistance of just one therapist. The questionnaire demonstrated high levels of acceptability amongst users. There were no Serious Adverse Events. CONCLUSIONS: This first interim analysis of RAPPER II shows that it is feasible and safe for people with SCI to use the REX powered assisted walking device to ambulate and exercise in. Participants with tetraplegia and paraplegia could walk and perform a functional exercise program when standing needing only modest levels of assistance in most cases. User acceptability was high. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02417532 . Registered 11 April 2015.

Macroscopic and histologic analyses of de novo bone in the posterior spine at time of spinal implant removal.

STUDY DESIGN: Case series report. OBJECTIVE: To evaluate the macroscopic and histologic appearance of bone after implantation of bone marrow aspirate on mineralized collagen fiber (Healos) at 12 to 24 months postoperative. SUMMARY OF BACKGROUND DATA: Numerous bone graft substitutes are currently used for spinal fusion. The success of these technologies is usually determined by radiographic visualization at 1-year or 2-year follow-up. Although x-rays and computed tomography scans are among the best tools to identify bone, interpretation of these images can still lead to error. METHODS: Six subjects with prior spinal fusion were reoperated for spinal implant removal. All subjects had reached at least 11-month follow-up from their initial spinal surgery. The graft material used in all fusion sites was bone marrow aspirate with Healos (BMA-H), except in a case where autograft was used on one side and BMA-H on the other. At implant removal, macroscopic appearances of the fusion sites were manually tested, photographed, and biopsies were taken and processed for routine histology. RESULTS: Macroscopic observations were critical to determine presence of mineralized or fibrous tissue. In the site implanted with autograft, fibrous tissue was observed macroscopically. This finding was confirmed by histology. In all sites implanted with BMA-H, solid bone was observed macroscopically. In 1 particular case, the newly formed fusion masses had a rectangular shape, reminiscent of that of the implanted strips. Histologically, BMA-H biopsies revealed mature cortico-cancellous bone. CONCLUSIONS: Published accounts of histologic evaluations of bone graft materials are uncommon, due to ethical and clinical limitations to harvesting tissue samples. Reoperations for instrumentation removal present rare occurrences when biopsies can be performed. In all cases, BMA-H implants resulted in solid, mature bone. These findings provide additional data on the effectiveness of BMA-H as a bone graft substitute for posterolateral fusion.

Facet joint cysts causing cauda equina compression.

Facet joint cysts are commonest at the L4-L5 level and are associated with facet joint degeneration and type III (degenerative) spondylolisthesis. It is extremely rare for facet joint cysts to cause symptomatic cauda equina compression. Three elderly patients presented to us with significant cauda equina compression caused by facet joint cysts. One presented with classic symptoms and signs of a cauda equina syndrome, a second with bilateral lower limb neurologic loss associated with uncontrolled epilepsy, and the third with bilateral leg symptoms as well as an upper limb tremor and fasciculation. The diagnosis was easily made after magnetic resonance scanning in two patients, although in one patient, it was significantly delayed because of his confounding neurologic picture. Lumbar spine surgery (decompression and cyst resection) was successful in resolving symptoms in all three, even though two patients had significant neurologic compromise before surgery. The occurrence of facet joint cysts in older patients can be associated with other degenerative neurologic conditions, and the diagnosis might not be apparent early. We suggest that in older patients who have a mixed picture of central and peripheral neurologic compromise, this diagnosis should be considered and investigation of the whole of the spine, not just the brain and spinal cord, should be undertaken.

Avascular necrosis of the femoral head after surgery for lumbar spinal stenosis.

STUDY DESIGN: Case report. OBJECTIVE: To report a previously undescribed complication of lumbar spinal surgery under prolonged hypotensive anesthesia. BACKGROUND DATA: Avascular necrosis of bone most commonly affects the femoral head. The etiology of the condition is understood in only 75% of cases. There have been no prior reports of this condition following lumbar spine surgery carried out under hypotensive anesthetic. METHODS: Notes review, clinical examination, plain radiographs, and magnetic resonance imaging diagnosed three patients who developed avascular necrosis of the femoral heads (five joints in total) after surgery for lumbar spinal stenosis. All three were treated with total hip replacement (five joints), and the diagnosis of avascular necrosis was confirmed in two by histopathological examination. RESULTS: All three patients have recovered full mobility following hip replacement surgery. None had any residual symptoms of lumbar spinal stenosis or hip disease, and none of them had shown any clinical evidence of avascular necrosis in any other bone. CONCLUSIONS: The development of avascular necrosis of the femoral heads following surgery for spinal stenosis may be due to hypotensive anesthesia, prone positioning on a Montreal mattress, or a combination of the two. Careful intraoperative positioning may reduce the risk of this occurring after spinal surgery. However, close postoperative 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 and treatment for this condition.

Delayed presentation of septic arthritis of a lumbar facet joint after diagnostic facet joint injection.

We report the case of a 46-year-old, otherwise healthy, man with chronic lower back pain and no evidence of nerve root compression who underwent diagnostic facet joint injections to assist in establishing where his pain sources were located and to try to help his spinal rehabilitation program. He presented with a facet joint infection 2 months after injection, in a manner that was indistinguishable from an acute intervertebral disc herniation. The diagnosis was confirmed on magnetic resonance imaging, and he was successfully treated with surgical debridement and antibiotics. Septic arthritis of a lumbar facet joint with an associated paraspinal abscess is a rare complication of facet joint infiltration with only two similar cases reported in the literature. We propose that this diagnosis be considered in patients who have undergone diagnostic facet joint injection who subsequently deteriorate with back and leg pain without another apparent cause.