A national survey on the management of foot drop secondary to lumbar degenerative disease in the United Kingdom.

PURPOSE: There is considerable variation in the management of foot drop secondary to lumbar degenerative disease (LDD) that occurs between centres and surgeons (spinal surgeons and neurosurgeons). The lack of standardised practice reflects the paucity in evidence base for management of this condition. In this survey, we aimed to assess current practice in the UK and identify the areas of variation. METHODS: A case-based survey was distributed to members of the Society of British Neurological Surgeons and British Association of Spine Surgeons through an online questionnaire. The survey consisted of 10 questions designed to determine the management of foot drop secondary to LDD. RESULTS: A total of 163 responses were collected among UK neurosurgeons and spinal surgeons with good geographical representation. 92% were Consultants. 86% of the respondents would offer surgery. The indication for offering surgery varied but 54% of respondents would offer surgery to patients who present with a painful foot drop. There was a huge variation in offering surgery dependent on the grade of weakness. The strongest prognostic indicator predicted was duration of weakness (92%). The timing of intervention was wide-ranging in the responses received. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice. CONCLUSIONS: This survey highlights the significant variability in management of foot drop secondary to LDD amongst consultant surgeons within the UK. It is also suggestive of a weak evidence base and indicates an urgent need for a high quality national prospective study.

Prognostic indicators of surgical outcome in painful foot drop: a systematic review and meta-analysis.

PURPOSE: Foot drop is a relatively uncommon presentation of lumbar degenerative disease and there is currently a paucity of evidence on management and outcomes which is reflective of the lack of standardised treatment provided to patients. The purpose of this systematic review and meta-analysis is to determine the effectiveness of surgical management and the factors that predict surgical outcome. METHODS: A systematic database search of Cochrane Library, Ovid Medline, Pubmed, Embase and Google Scholar was undertaken from inception through August 2018. Only studies reporting on surgical outcome in adult patients who had a painful foot drop and underwent decompression were included. Case reports and studies with surgical fixation were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Data were pooled using a random-effects model. RESULTS: 797 studies were screened and 9 observational studies met the inclusion criteria. This resulted in a total of 431 patients who underwent decompression for foot drop. Pooled rates of outcome for improvement in foot drop MRC grade were 84.5% (range 67.9-96%). Sub-group meta-analyses of studies revealed a statistically significant association between duration of foot drop (pooled 4.95 [95% CI 1.13-21.74]), severity of preoperative weakness (pooled 0.38 [95% CI 0.15-0.93]) on post-operative outcome and age (pooled 6.28 [1.33-29.72]). CONCLUSION: This is the first systematic review and meta-analysis to explore the outcome and prognostic indicators of lumbar decompression for foot drop. Findings indicate that age, duration of foot drop weakness and MRC grade of foot drop prior to intervention were strong predictors of surgical outcome.

Impact of COVID-19 pandemic on acute spine surgery referrals to UK tertiary spinal unit: any lessons to be learnt?

INTRODUCTION: Evidence is emerging, suggesting a significant drop in hospital referrals and attendances for various medical conditions due to the COVID-19 pandemic. With the implementation of lockdown rules, road traffic and outdoor activities were expected to drop, thereby reducing the number of high-energy spinal injuries. Critical non-traumatic spinal conditions like spinal tumours, infections, or compressive pathologies, however, should continue to present as before. We assessed all acute spinal referrals to our tertiary spine unit comparing with the acute activity for a similar time frame in the previous year. The aim was to identify any variance in the acute spinal activity, explain reasons for the discrepancy and identify any learning points. MATERIALS: All acute referrals to our tertiary spinal surgery unit made from 01 February 2020 to 30 April 2020 were evaluated. Similar data from the preceding year, i.e. 2019 was evaluated for comparison. Data were analysed for qualitative or quantitative changes in the referral pattern and their subsequent management outcomes. RESULTS: Spinal referral numbers reduced by 46.05% during the time frame of February-April 2020 when compared to the same period in 2019 (p < 0.017). Similarly, numbers of high-energy traumatic presentations reduced by 72% (p < 0.002). Referrals for critical spinal conditions declined by two-thirds for spinal infections and more than a third for spinal tumours. Emergency surgical workload waned by 27%, especially more so during the six-week lockdown duration. CONCLUSION: Reduction in spinal activity, even for critical spinal conditions, during the pandemic is likely due to a combination of factors like patient behaviour, fear of contracting COVID-19 infection during hospital visit, self-isolation advice, availability of a senior decision maker on the frontlines, and changes in healthcare service provisions. The health crisis may provide an opportunity for optimisation of spinal healthcare services both at the referring hospital and at the tertiary centre.

Does the external remote controller's reading correspond to the actual lengthening in magnetic-controlled growing rods?

PURPOSE: Magnetic-controlled growing rods (MCGRs) are now routinely used in many centres to treat early-onset scoliosis (EOS). MCGR lengthening is done non-invasively by the external remote controller (ERC). Our experience suggests that there may be a discrepancy between the reported rod lengthening on the ERC and the actual rod lengthening. The aim of this study was to investigate this discrepancy. METHODS: This was a prospective series. Eleven patients who were already undergoing treatment for EOS using MCGRs were included in this study. RESULTS: One hundred and ninety-two sets of ultrasound readings were obtained (96 episodes of rod lengthening on dual-rod constructs) and compared to their ERC readings. Only 15/192 (7.8%) readings were accurate; 27 readings (14.9%) were false positive; and 8 readings (4.2%) were an underestimation while 142 readings (74.0%) were an overestimation by the ERC. Average over-reporting by the ERC was 5.31 times of the actual/ultrasound reading. When comparing interval radiographs with lengthening obtained on ultrasound, there was a discrepancy with an average overestimation of 1.35 times with ultrasound in our series. There was a significant difference between ERC and USS (p = 0.01) and ERC and XR (p = 0.001). However, there was no significant difference between USS and XR (p > 0.99). CONCLUSION: The reading on the ERC does not equate to the actual rod lengthening. The authors would recommend that clinicians using the MCGR for the treatment of early-onset scoliosis include pre- and post-extension imaging (radiographs or ultrasound) to confirm extension lengths at each outpatient extension. In centres with ultrasound facilities, we would suggest that patients should have ultrasound to monitor each lengthening after distraction but also 6-month radiographs. These slides can be retrieved under Electronic Supplementary Material.

Sacroiliac joint fusion for low back pain: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Although pain is generally regarded as originating in the lumbar spine, it has been estimated that in 15-30 % of patients, LBP originates from the sacroiliac joint (SIJ). PURPOSE: To determine whether sacroiliac joint fusion (SIJF) for LBP is effective in reducing pain when the SIJ is known to be the pain generator. STUDY DESIGN/SETTING: Systematic review and meta-analysis. METHODS: A systematic literature review and meta-analysis was performed of observational studies describing outcome of SIJF in patients with LBP. Outcome measures were VAS pain, ODI, SF-36 PCS/MCS and Majeed score. The following databases were searched: PubMed, Web of Science, Embase, Medline and Google scholar. The methodological quality of selected studies was assessed using the National Heart Lung and Blood Institute case series quality assessment tool. Meta-analysis was used to combine the studies for each outcome and forest plots were prepared. Outcomes were expressed as mean difference (MD). RESULTS: Six studies were included in the meta-analysis with a mean follow-up of 17.6 months. All outcomes showed statistical and clinical improvement (VAS pain MD: 54.8; 95 % CI 48.6, 61.0; n = 380; p < 0.001, ODI MD: 14.5; 95 % CI 8.4, 20.6; n = 102; p < 0.001, SF-36 PCS MD: -19.5; 95 % CI -24.7, -14.2; n = 140; p < 0.001, SF-36 MCS MD: -8.5; 95 % CI -12.9, -4.1; n = 198; p < 0.001 and Majeed score MD: -35.4; 95 % CI -48.5, -22.2; n = 140; p < 0.001). CONCLUSIONS: SIJF appears to be a satisfactory procedure for alleviating pelvic girdle pain.

Acute lumbar radiculopathy with weak legs.

BACKGROUND: Inferior vena cava thrombosis is a rare but important cause of acute low back pain and lumbar radiculopathy. Failure to diagnose and treat this condition could result in propagation of the thrombosis, resulting in fatal pulmonary embolism. CASE REPORT: We report the first known case of inferior vena cava thrombosis in a postpartum woman presenting with acute lumbar radiculopathy and weak legs. She was successfully treated with i.v. heparin and oral anticoagulation. CONCLUSIONS: Inferior vena cava thrombosis is a rare cause of acute lumbar radiculopathy, but is in the differential diagnosis to consider, especially in those patients at increased risk of thrombosis.

Should a Lumbar MRI for back pain routinely include the sacro-iliac joint?

BACKGROUND: Back pain is a common problem and has been shown to affect approximately 85% of the adult population at any one time. The source of this pain can be difficult to identify and the sacroiliac joint (SIJ) has been proposed as a possible pain source. Its percentage contribution to lower back pain is controversial. Clinical provocative tests for SIJ pathology have been developed but these have high intra and inter-observer variability and the significant of positive findings is unclear. This study proposes that the SIJ should not be imaged as part of a routine MRI lumbar spine series. METHODS: We retrospectively reviewed the images of 353 patients who had MRI lumbar spine scans. 130 had the SIJ imaged. We recorded the clinical findings and diagnosis at referral. We reviewed the images and documented the radiological findings. RESULTS: SI joint pathology was most frequently identified when clinical suspected. Overall SIJ pathology found on MRI in only 0.02% of patients. CONCLUSIONS: We conclude that routinely imaging the SIJ in MRI lumbar spine series is not cost-effective or a useful use of resources. The SIJ should be imaged only if significant clinical findings are demonstrated.

A multi-centred audit of secondary spinal assessments in a trauma setting: are we ATLS compliant?

PURPOSE: The global incidence of spinal cord injuries varies with the developed world having improved survival and 1 year mortality in a poly-trauma setting. This improved survival has been estimated at 20 % in a recent Cochrane review of Advanced Trauma Life Support (ATLS).The aim of this audit is to evaluate the management of patients with suspected spinal cord injury by the trauma and orthopaedic team in three centres in South Wales. METHODS: A retrospective case note review of the secondary survey was performed. Inclusion criteria were patients 18 years and above, with poly-trauma and presenting to Accident and Emergency department at the treating hospital. We used ATLS guidelines as an audit tool and reviewed the documentation of key components of the secondary assessment. RESULTS: Forty-nine patients were included (29 males, 20 females) with an average age of 53.7 years (19-92 years). We found that completion of all components of the secondary survey for spinal injury was poor, 29 % receiving a digital per rectal examination despite suspected spinal injury. Paralysis level was not documented in 20.4 % of patients. Medical Research Council grade was only documented in 24.5 % although was assessed in 73.5 %. The secondary survey took place after 2 h in 54.6 % of patients. CONCLUSION: We found that the documentation of the performance of a secondary survey was poor. We found that most patients included in this study are not currently meeting the minimal standard suggested by the ATLS guidelines.

Management of metastatic spinal cord compression: awareness of NICE guidance.

OBJECTIVE: The spine is the most common site for bony metastases. It can lead to the development of significant complications and morbidity if appropriate treatment is not provided. National Institute for Health and Clinical Excellence (NICE) issued new guidance in 2008 with regard to the management of patient with metastatic spinal cord compression (MSCC) to assess the awareness of the NICE guidelines for MSCC. METHODS: We contacted doctors in oncology, trauma and orthopaedics, palliative care and general medicine and assessed their knowledge of MSCC using a questionnaire based on the salient points of the NICE guidance. This was a UK-wide questionnaire. RESULTS: We contacted 96 trainee doctors (oncology, palliative care, general medicine and orthopaedics) and found that 74 % felt adequately informed to diagnose metastatic cord compression although only 11 % considered a sensory level as a potential sign of cord compression. Neurological symptoms (91 %) were the main reason for referral to a tertiary spinal service. MRI was the investigation of choice. There was a poor knowledge of metastatic scoring systems and only 8 % would consider assessing the patient's fitness for surgery. Most of the respondents felt that they had been poorly taught at undergraduate and postgraduate level on MSSC. CONCLUSION: Our audit shows that MSCC is poorly understood in general and that greater understanding of the NICE guidance is required to allow for better management of these patients and more prompt referral for appropriate surgical assessment.

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases.

STUDY DESIGN: Guideline. OBJECTIVES: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions. METHODS: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. RESULTS: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. CONCLUSION: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline.

A 3D motion analysis study comparing the effectiveness of cervical spine orthoses at restricting spinal motion through physiological ranges.

OBJECTIVE: To compare the effectiveness of the Aspen, Aspen Vista, Philadelphia, Miami-J and Miami-J Advanced collars at restricting cervical spine movement in the sagittal, coronal and axial planes. METHODS: Nineteen healthy volunteers (12 female, 7 male) were recruited to the study. Collars were fitted by an approved physiotherapist. Eight ProReflex (Qualisys, Sweden) infrared cameras were used to track the movement of retro-reflective marker clusters placed in predetermined positions on the head and trunk. 3D kinematic data were collected during forward flexion, extension, lateral bending and axial rotation from uncollared to collared subjects. The physiological range of motion in the three planes was analysed using the Qualisys Track Manager System. RESULTS: The Aspen and Philadelphia were significantly more effective at restricting flexion/extension than the Vista (p < 0.001), Miami-J (p < 0.001 and p < 0.01) and Miami-J Advanced (p < 0.01 and p < 0.05). The Aspen was significantly more effective at restricting rotation than the Vista (p < 0.001) and the Miami-J (p < 0.05). The Vista was significantly the least effective collar at restricting lateral bending (p < 0.001). CONCLUSION: Our motion analysis study found the Aspen collar to be superior to the other collars when measuring restriction of movement of the cervical spine in all planes, particularly the sagittal and transverse planes, while the Aspen Vista was the least effective collar.

Predictive value of post-void residual volume as an adjunctive tool in the clinical evaluation of cauda equina syndrome.

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an 'exclusion tool', and it should only be used as an adjunct to a full clinical assessment.

Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial.

Aims: Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS). Methods: UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion: The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.

Comparison of aprotinin and tranexamic acid in adult scoliosis correction surgery.

PURPOSE: A retrospective review of consecutive adult patients undergoing scoliosis correction surgery was performed to compare the effects of aprotinin and tranexamic acid in blood conservation and to define a comprehensive blood conservation strategy for such surgery. METHODS: Medical records of all patients who underwent scoliosis correction surgery in this unit between January 2003 and December 2008 were reviewed. The patients were divided into three cohorts: group 1 receiving no antifibrinolytics, group 2 aprotinin and group 3 tranexamic acid. Information was collected regarding number of vertebral levels fused, pre- and post-operative haemoglobin, intra-operative blood loss and peri-operative autologous and allogenic blood transfusion performed. RESULTS: Aprotinin was used in 28 patients (38%), tranexamic acid in 26 (36%), while 19 (26%) received no antifibrinolytics. 21 patients had anterior surgery, 34 patients had posterior surgery and 18 had combined anterior and posterior procedures. Mean blood loss in the patients who received aprotinin and tranexamic acid was 710 and 738 ml, respectively. This was significantly less than the patients receiving no antifibrinolytics (972 ml, p = 0.037). Blood transfusion was required in only two patients undergoing anterior correction surgery. CONCLUSION: Aprotinin and tranexamic acid reduce blood loss in adult spinal deformity correction surgery. With aprotinin being unavailable for clinical use, we recommend the use of tranexamic acid along with other blood conservation measures for adult spinal deformity correction surgery.

Posterior spinal stabilization: A biomechanical comparison of Laminar Hook Fusion to a Pedicle Screw System.

BACKGROUND: Several spine instrumentation techniques have been introduced to correct inter-segmental alignment, or provide long-term stability. Whilst pedicle screws are considered the intervention of reference, we hypothesize that the week hold of osteoporotic bone, might be a clinical indicator for an alternative surgical approach. METHODS: To put this to the test, a non-linear Finite Element model, of a ligamentous lumbosacral spine, was employed to examine a stabilization spanning over L3-L5. Two different immobilization techniques (a Pedicle Screw System and Laminar Hook Fusion) are compared as to their biomechanical response during 7.5 Nm flexion, lateral flexion and torsion, while considering a 280 N follower load. Fifteen analyses performed in total, simulating patients of healthy and osteoporotic Bone Mineral Density. FINDINGS: Range of Motion was significantly reduced after instrumentation for both implant systems. This trend was more pronounced in the Pedicle Screw models, which were stressed to a higher degree. To evaluate implant loosening risk, we introduce the consideration of strain energy patterns around the screw tract. The notably higher intensity of these, for the osteoporotic model, taken into consideration with the weaker strength of the tissue and inconsistencies in the stress allocation between implant and bone, affirmed an increased risk for loosening of the Pedicle Screws in osteoporotic patients. INTERPRETATION: The analysis provided refined insight as to the treatment of osteoporotic patients as well as to their postoperative care, as restriction of specific movements (e.g. through bracing), could significantly restrict the stress values in the bone-implant interface and thus, reduce implant failure.

Surgery versus conservative management of stable thoracolumbar fracture: the PRESTO feasibility RCT.

BACKGROUND: There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. OBJECTIVES: To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. DESIGN: External randomised feasibility study, qualitative study and national survey. SETTING: Three NHS hospitals. METHODS: A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. PARTICIPANTS: Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. INTERVENTIONS: Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. MAIN OUTCOME MEASURE: Recruitment rate (proportion of eligible participants randomised). RESULTS: Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study (n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. LIMITATIONS: Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. CONCLUSIONS: A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. FUTURE WORK: Development of consensus regarding the population of interest for a trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12094890. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.

Fractures occurring in the mid- to low back region (or thoracolumbar fractures) are the most common back fractures. When the fracture is stable with no spinal nerve injury, there is uncertainty whether treatment with surgery or non-surgical treatment (e.g. stabilising the spine with a brace) results in the best outcome for patients. The Pragmatic Randomised Evaluation of Stable Thoracolumbar fracture treatment Outcomes (PRESTO) study aimed to explore whether or not it would be feasible to carry out a full-scale study to find out which of these two treatments works best. Adults aged ≥ 16 years being treated for these fractures in three hospitals were invited to take part in the study. Over the course of 1 year, we assessed how many patients were treated, the number who met the study entry criteria and the proportion of eligible patients who agreed to take part. Staff and patients were interviewed about the study processes and their experiences of taking part. Spine surgeons from around the UK were also asked to complete an online survey, which asked questions about the treatment of patients with this fracture. There were fewer patients than expected who met the study entry criteria and, of these, fewer patients who agreed to take part. There were differences among surgeons about the definition of a stable fracture, and we found that surgeons have strong views about whether or not surgery is appropriate when fractures are stable. We also found that more support would be required for the staff involved in inviting patients to take part in a bigger study, and that the format and content of information provided to patients needs to be improved. The findings of the PRESTO study showed that a large trial is unlikely to be successful at this time; however, we have provided important information for future research into the treatment of these fractures.

The Relative Merits of Posterior Surgical Treatments for Multi-Level Degenerative Cervical Myelopathy Remain Uncertain: Findings from a Systematic Review.

OBJECTIVES: To assess the reporting of study design and characteristics in multi-level degenerative cervical myelopathy (DCM) treated by posterior surgical approaches, and perform a comparison of clinical and radiographic outcomes between different approaches. METHODS: A literature search was performed in Embase and MEDLINE between 1995-2019 using a sensitive search string combination. Studies were selected by predefined selection criteria: Full text articles in English, with >10 patients (prospective) or >50 patients (retrospective), reporting outcomes of multi-level DCM treated by posterior surgical approach. RESULTS: A total of 75 studies involving 19,510 patients, conducted worldwide, were identified. Laminoplasty was described in 56 studies (75%), followed by laminectomy with (36%) and without fusion (16%). The majority of studies were conducted in Asia (84%), in the period of 2016-2019 (51%), of which laminoplasty was studied predominantly. Twelve (16%) prospective studies and 63 (84%) retrospective studies were identified. The vast majority of studies were conducted in a single centre (95%) with clear inclusion/exclusion criteria and explicit cause of DCM. Eleven studies (15%) included patients with ossification of the posterior longitudinal ligament exclusively with cohorts of 57 to 252. The clinical and radiographic outcomes were reported with heterogeneity when comparing laminoplasty, laminectomy with and without fusion. CONCLUSIONS: Heterogeneity in the reporting of study and sample characteristics exists, as well as in clinical and radiographic outcomes, with a paucity of studies with a higher level of evidence. Future studies are needed to elucidate the clinical effectiveness of posterior surgical treatments.

Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death.

Ankylosing spondylitis is a seronegative spondyloarthropathy which predominantly affects the sacroiliac joints and the spine. The spine can become very kyphotic with time. Minor trauma is sufficient to produce a fracture, because of the underlying osteoporosis and because the ankylosed segments constitute large leverage arms. These fractures are unstable because the soft tissues are ossified and also involved in the fracture. Cervical spine fractures need an immobilisation which respects the pre-injury flexion deformity. Inadvertent application of a rigid collar which forces the previously flexed cervical spine into extension may lead to neurological deterioration and even death. We report such a case in a 59-year-old male patient.

Is it mandatory to routinely use image intensifier during scoliosis surgery? - Results of an email survey.

BACKGROUND: It is now considered standard of care to use Spinal cord monitoring during scoliosis surgery. Use of Image intensifier during scoliosis surgery, on the other hand, is highly variable in United Kingdom (UK) spine centres. Our objective was to evaluate the use of image intensifier during scoliosis surgery in UK spine centres. METHODS: Ninety three British scoliosis spine surgeons were invited to complete a survey via email using Survey Monkey platform. Surgeons were asked about the routine use of image intensifier during scoliosis surgery, including the reasons for using it and if, in their opinion, routine use is medico-legally mandatory. RESULTS: Thirty four Spine surgeons replied (response rate of 36.5%). Among these 85% have been consultants for at least 5 years. 91% performed more than 10 paediatric scoliosis operations per annum and 53% performed more than 30 operations per annum. 68% always routinely use image intensifier during scoliosis surgery while 21% do not use it routinely. However 66% mentioned that in their opinion, it is not medico-legally mandatory to use the Image intensifier during scoliosis surgery and that routine use should be left to the discretion of the operating surgeon. CONCLUSIONS: Although majority of the United Kingdom spine surgeons, who responded to this survey, routinely use image intensifier during scoliosis surgery, they agree that it is not medico-legally mandatory to routinely use the image intensifier.

Pragmatic randomised evaluation of stable thoracolumbar fracture treatment outcomes (PRESTO): study protocol for a randomised controlled feasibility trial combined with a qualitative study and survey.

BACKGROUND: A thoracolumbar fracture is the most common fracture of the spinal column. Where the fracture is not obviously stable or unstable, the optimal management is uncertain. There are variations between surgeons, treating centres and within the evidence base as to whether surgical or non-surgical approaches should be used. In addition, the boundaries of this zone of uncertainty for stability are unclear.This study has been designed in response to an NIHR HTA commissioning brief to assess the feasibility of undertaking a large-scale trial to evaluate the effectiveness of surgical and non-surgical treatments for thoracolumbar fractures without neurological deficit. METHODS: Assessment of feasibility will be addressed through three elements: a randomised external feasibility study, a national survey of surgeons and a qualitative study.The external feasibility study is a pragmatic, parallel-group, randomised controlled trial comparing surgical fixation (intervention) versus non-surgical management (control). Recruitment will take place in three secondary care centres in the UK.The primary outcome is recruitment rate, defined as the proportion of eligible participants who are randomised. Further outcomes related to recruitment, randomisation, drop-out, cross-over, loss to follow-up, completeness of outcome data, study processes and details of the interventions delivered will be collected.The survey of surgeons and qualitative study of clinicians, recruiting staff and patients will enhance the feasibility study, enabling a broad overview of current practice in the field in addition to perceived facilitators and barriers to running a full-scale trial. DISCUSSION: PRESTO is a feasibility study which aims to inform methodology for a definitive trial comparing surgical fixation with non-surgical management for patients with stable thoracolumbar fractures. TRIAL REGISTRATION: The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN12094890). Date of registration was 22/02/2018 (http://www.isrctn.com/ISRCTN12094890).