A comparison of available guidelines for the detection of cauda equina syndrome and assessing the need for further clinical guidance in Ireland.

The cauda equina syndrome (CES) is a rare but critical disorder, which can result in devastating motor weakness and sensory deficit, alongside often irreversible bladder, bowel and sexual dysfunction. In addition to the clinical burden of disease, this syndrome results in a disproportionately high medicolegal strain due to missed or delayed diagnoses. Despite being an emergency diagnosis, often necessitating urgent surgical decompression to treat, we believe there is a lack of clarity for clinicians in the current literature, with no published Irish guideline concerning screening or detection. The current study aims to identify and analyse appropriate guidelines in relation to CES screening which are available to clinicians in Ireland. The study design included a comprehensive literature review and comparison of existing guidelines. The review identified 13 sources of appropriate guidance for clinicians working in Ireland. These resources included textbooks, websites and guidelines developed in the UK. No Irish guidelines or advice were available on CES screening/treatment at the time of review. This review demonstrated the lack of consensus and guidance for clinicians in Ireland on how to effectively screen for CES, judge who requires further imaging and investigations and how to rule out the condition. A national consensus on thorough screening and prompt investigation for CES is necessary, and the formulation of new CES guidelines would be a welcome addition to what is available to clinicians currently.

A novel scoring system incorporating sarcopenia to predict postoperative survival in spinal metastasis.

BACKGROUND CONTEXT: As the prevalence of spinal metastasis rises, methods to predict survival will become increasingly important for clinical decision-making. Sarcopenia may be used to predict survival in these patients. PURPOSE: The purpose of this study to develop a prediction model incorporating sarcopenia for postoperative survival in patients with spinal metastasis. DESIGN: Retrospective cohort study. PATIENT SAMPLE: This study included 200 patients who underwent operative intervention for spinal metastasis in our institution, a tertiary, academic spine center. OUTCOME MEASURES: The primary outcome measure was 1-year postoperative survival. The secondary outcome measures were 3-month and 6-month postoperative survival. METHODS: Clinicopathological and survivorship data was collated. Sarcopenia was defined using the L3 Psoas/Vertebral Body Ratio on cross-sectional CT. Independent predictors of postoperative survival were assessed by multiple logistic regression. RESULTS: Overall 1-year postoperative survival was 50%. L3/Psoas ratio ≥1.5 (OR 6.2), albumin ≥35g/l (OR 3.0) and primary tumor type were found to be independent predictors of 3 month, 6 month and 1 year postoperative survival on multivariable analysis. Age at surgery, ambulatory status and mode of presentation were not independent predictors of survival. Variables were used to generate a new scoring system, ProgMets, to predict postoperative survival. The ProgMets system had greater correlation and higher area under the curve (AUC, 0.80) for 1-year survival than other scoring systems. CONCLUSIONS: This is the first model to incorporate sarcopenia to predict survival in spinal metastasis patients and has good prediction of survival compared to previous models. This tool may be increasingly useful for informed decision making for patients and surgeons.

Thermal Generation in Spinal Surgery: Does Rate of Irrigation Matter During Anterior Cervical Discectomy?

BACKGROUND: High-speed rotational burring is considered the mainstay of modern spinal decompression surgery. However, high-energy burrs generate significant heat due to the friction between the bone and the rotating burr. This study determines the effects of automated irrigation rate on burr tip temperatures either with a serrated steel burr or diamond-coated burr during anterior cervical discectomy and fusion (ACDF). METHODS: This is an observational study of the routine practice of a single surgeon for 20 patients aged 18 years or older undergoing elective single- or multilevel ACDF. Various continuous irrigation rates of 0, 0.5, 1.0, or 2.0 cc/min were used. Forward-looking infrared thermography was used to measure the burr tip temperatures. The Midas Rex Legend EHS (Medtronic, PLC, Minneapolis, MN) stylus high-speed surgical drill was used with 3-mm burrs (diamond-coated and carbide-serrated steel) paired to the Medtronic Integrated Power Console set at 60,000 rpm. RESULTS: The 0.5-cc/min irrigation rate kept the maximum burr temperatures below 45°C (P < .001). With no irrigation (0 cc/min), the steel burrs reached a maximum of 141°C, and the diamond-coated burrs reached 177°C, which was the only significant difference related to the burr materials (P = 0.0354). With irrigation rates of 0.5 cc/min and above, the maximum recorded temperature for steel burrs was 40.6°C, and the maximum temperature for diamond-coated burrs was 38.9°C. Irrigation rates greater than 0.5 cc/min yielded little additional benefit. CONCLUSION: This study highlights the importance of adequate irrigation during high-speed burr drilling. Continuous irrigation is recommended even as low as 0.5 cc/min. It is good operative practice to reduce the risk of heat transmission to surrounding tissues, especially considering the proximity of cervical spinal nerve roots during uncoforaminal decompression.

Review of the Role of Intraoperative Neurophysiological Monitoring in Spinal Surgery With a Focus on the True and False Positives and a Clinical Correlation.

BACKGROUND: Spinal surgery is a technically challenging endeavor with potentially devastating complications. Intraoperative neurophysiological monitoring (IONM) is a method of preventing and identifying damage to the spinal cord. OBJECTIVE: The aim of our study was to examine the clinical utility of IONM in spinal surgeries performed at our institution and what effect, if any, subsequent interventions had on postoperative patient outcomes. METHODS: This is a retrospective cohort study of 169 patients who underwent spinal surgery with IONM at 2 institutions between 2013 and 2018. Signal changes detected were recorded as well as the surgeon's response to these changes. Neurological status was recorded using a standard neurological examination and characterized as per the McCormick Neurological Scale. Patients were followed up for 12 months after surgery. RESULTS: A total of 169 spinal surgery cases with concurrent use of spinal cord monitoring were carried out in our institution between 2013 and 2018. The youngest patient was 14 years old, and the oldest was 92 years old (mean, 51.9 ± 19.6 years). There were 100 female patients and 69 male patients. Most patients (n = 124) had no signal changes. Signal changes were observed in 26.6% of the cases (n = 45). Most of these signal changes were rectified through repositioning of the patient (n = 24). The other 21 patients saw no improvement in their signals before the end of their procedures; however, these 21 patients had no postoperative deficits (grade I). This brought the false positive rate to 38% (21/55); the false negative rate was 1.8% (3/169). CONCLUSION: This study showed similar outcomes in patients whether IONM signals were recovered or not. The false positive and false negative rates were high. Our study helps to raise awareness about IONM's strengths and weaknesses to inform future clinical practice. We recommend prioritizing clinical judgment in spinal surgery cases and using IONM with caution.

Spinal metastasis: The rise of minimally invasive surgery.

INTRODUCTION: Bone is the third most common site of metastatic cancer, of which the spine is the most frequently involved. As metastatic cancer prevalence rises and surgical techniques advance, operative intervention for spinal metastases is expected to rise. In the first operative cohort of spinal metastasis in Ireland, we describe the move towards less invasive surgery, the causative primary types and post-operative survival. METHODS: This is a retrospective cohort study of all operative interventions for spinal metastasis in a tertiary referral centre over eight years. Primary spinal tumours and local invasion to the spine were excluded. Median follow up was 1895 days. RESULTS: 225 operative procedures in 196 patients with spinal metastasis were performed over eight years. Average cases per year increased form 20 per year to 29 per year. Percutaneous procedures became more common, accounting for the majority (53%) in the final two years. The most common primary types were breast, myeloma, lung, prostate and renal. Overall survival at 1 year was 51%. Primary type was a major determinant of survival, with breast and the haematological cancers demonstrating good survival, while lung had the worst prognosis. CONCLUSION: This is the first descriptive cohort of operative interventions for spinal metastasis in an Irish context. Surgery for spinal metastasis is performed at an increasing rate, especially through minimally-invasive means. The majority of patients survive for at least one year post-operatively. Prudent resource planning is necessary to prepare for this growing need.

A Rare Paraspinal Desmoid Tumour following Instrumented Scoliosis Correction in an Adolescent.

Desmoid tumours are benign neoplasms of myofibroblasts, often occurring after soft-tissue trauma. Rarely, desmoid tumours can occur following operative intervention, including spine surgery. In this case report, we describe the first reported case of desmoid tumour following scoliosis corrective surgery in an adolescent.

Does country of origin influence research outcomes in operative interventions for lumbar spinal stenosis?

INTRODUCTION: Bias undermines evidence-based decision making. To counter this, surgeons must be aware of biases that may influence studies' reported outcomes. Lumbar spinal stenosis often requires operative intervention, with multiple available surgical strategies. Our aim was to assess the role that country of origin plays in published surgical outcomes for lumbar spinal stenosis. METHODS: We performed a search strategy of MEDLINE and EMBASE for all English language primary research papers evaluating operative interventions for lumbar spinal stenosis during the years 2010-2019 inclusive. Small case series and meta-analyses were excluded. Papers were assessed for outcome positivity and country of origin. Data analysis was conducted using GraphPad Prism statistical software. RESULTS: A total of 487 papers met the inclusion criteria. Of these, 419 (86%) reported positive outcomes. Asian studies were the most likely to report positive outcomes, at 93% (220 of 236), followed by US studies at 89% (98 of 110). European studies had the lowest positive publication rate at 69% (84 of 121). Region of origin was an independent predictor of positive study outcome on multivariable analysis when controlling for different study designs and healthcare systems. CONCLUSION: There is an association between country of origin and positive reported outcome in studies evaluating interventions for lumbar spinal stenosis. Clinicians should consider this when making management decisions based on published evidence. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Osteoporotic Vertebral Fractures are Common in Hip Fracture Patients and are Under-recognized.

INTRODUCTION: The vertebrae are the most common site for osteoporotic fracture. While they can result in disability and increased mortality, only one-third present clinically. People with multiple fractures are at greater risk of future fractures. Most hip fracture patients are neither diagnosed nor treated for their underlying osteoporosis. Computed tomography (CT) studies are often performed on hospitalised patients, can be used to diagnose osteoporosis and are gaining popularity for opportunistic osteoporosis screening by measuring BMD and other bone strength indices. The aim of this study was to assess the prevalence of vertebral fractures on CT pulmonary angiograms (CTPA) in a cohort of hip fracture patients and whether this increased their diagnosis and treatment rates. METHODS: We retrospectively identified all hip fractures admitted to our institution between 2010 and 2017 to identify those who underwent CTPA scans. An independent, blinded consultant musculoskeletal radiologist reviewed the images for vertebral fractures and quantified severity using Genant criteria. Results were compared to the original radiology report, discharge diagnoses and treatment rates for osteoporosis. RESULTS: Eleven percent (225/2122) of patients had CTPA images available. Seventy percent (158) were female with a mean age of 78 years (SD: 11). The median length of stay for all patients was 16 days (1-301). Forty percent (90) of patients had at least one vertebral fracture present and 20% (46) had more than one fracture. Only one in 5 radiology reports noted the fractures. 24% of subjects had osteoporosis treatment recorded at hospital discharge and there was no difference between those with vertebral fractures to those without. CONCLUSION: Many hip fracture patients have undiagnosed spine fractures. A screening strategy which evaluates CT scans for fractures has potential to increase diagnosis and treatment rates of osteoporosis. However, more work is needed to increase awareness.

The rise of metastatic bone disease in Ireland.

To describe the expected rise of metastatic bone disease in Ireland, the relative primary types, and the locations of spread within the skeleton. This was a population-based epidemiological study using cancer registry data. We included patients with known metastatic cancer to bone, within 1 year of the primary diagnosis, during the years 1994 to 2012 inclusive. Our main outcome measures were age-specific, gender-specific and age-standardised incidence rates of bone metastasis, primary types and metastatic location within the skeleton. There were 14,495 recognised cases of bone metastasis in Ireland, 1994-2012 inclusive. Cases consistently rose over the time period, with 108% case increase and 51% age-standardised incidence rise. Annual percentage change increased across both genders and over all age groups. Most of this rise was not due to demographic population change. Breast, prostate and lung accounted for the majority of primary types. GI cancers were the fourth most common primary type. There were proportional increases in breast and lung, with proportional decreases in prostate. The spine was the major metastatic site. Bone metastasis is a significant and rising healthcare concern in Ireland. This rise is disproportionate to demographic changes. Breast, prostate and lung cancers account for the majority. GI cancers are implicated in an unexpectedly high number of cases. Spine is the most common location of bony metastasis, especially at presentation. Prudent healthcare planning is necessitated to prepare for the growing consequences of bone metastasis in cancer patients.

Bone Mineral Is More Heterogeneously Distributed in the Femoral Heads of Osteoporotic and Diabetic Patients: A Pilot Study.

Osteoporosis is associated with systemic bone loss, leading to a significant deterioration of bone microarchitecture and an increased fracture risk. Although recent studies have shown that the distribution of bone mineral becomes more heterogeneous because of estrogen deficiency in animal models of osteoporosis, it is not known whether osteoporosis alters mineral distribution in human bone. Type 2 diabetes mellitus (T2DM) can also increase bone fracture risk and is associated with impaired bone cell function, compromised collagen structure, and reduced mechanical properties. However, it is not known whether alterations in mineral distribution arise in diabetic (DB) patients' bone. In this study, we quantify mineral content distribution and tissue microarchitecture (by µCT) and mechanical properties (by compression testing) of cancellous bone from femoral heads of osteoporotic (OP; n = 10), DB (n = 7), and osteoarthritic (OA; n = 7) patients. We report that though OP cancellous bone has significantly deteriorated compressive mechanical properties and significantly compromised microarchitecture compared with OA controls, there is also a significant increase in the mean mineral content. Moreover, the heterogeneity of the mineral content in OP bone is significantly higher than controls (+25%) and is explained by a significant increase in bone volume at high mineral levels. We propose that these mineral alterations act to exacerbate the already reduced bone quality caused by reduced cancellous bone volume during osteoporosis. We show for the first time that cancellous bone mineralization is significantly more heterogeneous (+26%) in patients presenting with T2DM compared with OA (non-DB) controls, and that this heterogeneity is characterized by a significant increase in bone volume at low mineral levels. Despite these mineralization changes, bone microarchitecture and mechanical properties are not significantly different between OA groups with and without T2DM. Nonetheless, the observed alterations in mineral heterogeneity may play an important tissue-level role in bone fragility associated with OP and DB bone. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

A systematic review of the Irish osteoporotic vertebral fracture literature.

INTRODUCTION: Vertebral fractures (VF) are the most common osteoporotic fracture. They are associated with significant morbidity and mortality and are an important predictor of future fractures. The epidemiology of VF in Ireland is limited and a greater understanding of their scale and impact is needed. Therefore, we conducted a systematic review of publications on osteoporotic VF in Ireland. METHODS: Systematic searches were conducted using PubMed, Medline, Embase, Scopus and Cochrane electronic databases to identify eligible publications from Ireland addressing osteoporotic VF. RESULTS: Twenty studies met the inclusion criteria out of 1558 citations. All studies were published since 2000. Data was obtained on 182,771 patients with fractures. Nine studies included more than 100 subjects and three included more than 1000. Females accounted for 70% with an overall mean age of 65.2 years (30-94). There was significant heterogeneity in study design, methods and outcome measures including the following: use of administrative claims data on public hospital admissions, surgical and medical interventions, the impact of a fracture liaison service and the osteoporosis economic burden. The prevalence of VF was difficult to ascertain due to definitions used and differences in the study populations. Only two studies systematically reviewed spine imaging using blinded assessors and validated diagnostic criteria to assess the prevalence of fractures in patient cohorts. CONCLUSIONS: Several studies show that VF are common when addressed systematically and the prevalence may be rising. However, there is a deficit of large studies systematically addressing the epidemiology and their importance in Ireland.

An analysis of whiplash injury outcomes in an Irish population: a retrospective fifteen-year study of a spine surgeon's experience.

BACKGROUND: Whiplash injuries result from an acceleration-deceleration injury of the cervical spine. The associated symptoms may include neck pain/stiffness; cervicogenic headaches; interscapular pain; upper limb pain, paraesthesia and weakness. Current treatment protocols recommend conservative management of low-grade whiplash. AIMS: To assess changing practices over time in the management of whiplash-associated disorders in the practice of a specialist spine surgeon and to explore the impact of associated litigation on this patient cohort. METHODS AND RESULTS: The private medical records of a specialist spine surgeon over a 15-year period (1996-2011) were reviewed. Three hundred one consecutive patients were identified: 169 females and 132 males with a mean age of 37 years ± 13. All were referred by primary care with potential soft tissue injury of the cervical spine following a road traffic accident. Fifty-eight percent had associated back pain. An initial conservative approach was adopted in all cases. Subsequently, 4 patients underwent surgical intervention. Ninety-three percent reported chronic neck pain > 6 months after their injury. Age was the only significant predictor of chronic neck pain (adjusted OR 1.29 for every 5-year increase, p = 0.03). All were ultimately involved in litigation. The establishment of the Personal Injuries Board did not influence the litigation duration during the study period. CONCLUSION: Whiplash poses a significant societal economic burden in Ireland and was associated with prolonged symptoms including neck pain and upper limb neuropathic symptoms in this cohort. Associated low-back pain was common. Litigation was linked with presentation in all cases.

Do medical students believe the back pain myths? A cross-sectional study.

BACKGROUND: Low back pain (LBP) is common, affecting 58-84% of adults at some point. In benign cases, misinformation can lead to harmful coping strategies and prolonged recovery time. Deyo has identified seven 'Myths of Back Pain' as misconceptions commonly seen in clinical practice of which doctors-in-training should be aware. We sought to determine medical students' baseline knowledge of the prognosis and management of LBP compared to the general public and to dispel the 'Myths of Back Pain'. METHODS: We carried out a cross-sectional study of medical students (pre-clinical and clinical) at the National University of Ireland, Galway where students completed a questionnaire outlining the seven 'Myths of Back Pain'. Final year students completed the survey before and after a seminar on LBP. Students' results were compared with a random sample of the public who attended Galway University Hospital. RESULTS: Two hundred nineteen students completed the questionnaire (59% female, 41% male). The mean age was 21 years (17-32). The mean number of correct answers increased according to medical school year (premedical 3/7, first year 4/7, final year 5/7). A personal history of back pain and female sex were associated with higher scores. On average, medical students answered 4/7 questions correctly overall, compared to the public (n = 131) who averaged at 3/7. Final years dispelled one further myth after their LBP seminar. CONCLUSIONS: Common misconceptions around LBP are prevalent among medical students and the general public. It is important that medical school curricula address these issues as part of their musculoskeletal programme.

Management of Metastatic Spinal Cord Compression in Ireland: Are Surgeons Overlooked?

BACKGROUND: The National Institute of Health and Clinical Excellence (NICE) provide a framework of evidence-based guidelines for the management of metastatic spinal cord compression (MSCC). We aimed to compare our center's provision of service to these best practice guidelines and discuss key shortcomings with their implications for the spinal surgeon. METHODS: Patients with radiologic evidence of MSCC over a 30-month period were identified using the hospital electronic radiological database. A chart review was performed analyzing MSCC management. RESULTS: Forty-one patients were identified. Pain was the most common presenting complaint, occurring in 76% of patients. Radiotherapy alone was the most common therapy employed (93% of patients). A surgical opinion was sought for 51% of patients. Histological diagnosis of the causative lesion occurred in 5 patients from surgical specimens. CONCLUSIONS: Incongruities between NICE guidelines and our practice exist. Early involvement of the spinal surgical services needs to be encouraged. Establishing a histological diagnosis of the spinal lesion should be seen as of therapeutic importance.

Comparison of thermal spread with the use of an ultrasonic osteotomy device: Sonopet ultrasonic aspirator versus misonix bonescalpel in spinal surgery.

BACKGROUND: The development of high speed rotating burrs has greatly advanced spinal surgery in recent years. However, they produce unwanted frictional heat and temperature elevation during the burring process. We compare the misonix bone scalpel (MBS) and the Sonopet ultrasonic aspirator to assess which would be the safer device in terms of the risk of thermal injury following laminectomy. METHODS: We describe an experimental nonrandomized study comparing two ultrasonic osteotomy devices. We use the device tip temperature and temperature of inner cortex of the lamina, following laminectomy, as the primary outcome. Our secondary outcome is to assess which device is associated with a lower risk of osteonecrosis and potential thermal injury to surrounding dura and nerves. RESULTS: The average device tip temperature for the Sonopet ultrasonic aspirator following the process of laminectomy was 36.8 with a maximum temperature of 41.8°C. The average device tip temperature for the MBS following laminectomy was 48.6 with a maximum temperature of 85.3°C. CONCLUSION: Our results have demonstrated the safety of the Sonopet ultrasonic aspirator with the Nakagawa serrated knife with temperatures below the threshold for osteonecrosis and thermal neural injury. However, the MBS has shown to occasionally reach high temperatures above the threshold of potential thermal injury to surrounding nerves and dura for a very short period of time. We advise to withdraw and re-insert the ultrasonic tip repeatedly to re-establish adequate cooling and lubrication. Further studies should be carried out using cadaveric bone at body temperature to simulate more accurate results.

Spinal Metastatic Disease: A Review of the Role of the Multidisciplinary Team.

Historically, a simple approach centered on palliation was applicable to the majority of patients with metastatic spinal disease. With advances in diagnosis and treatment, a more complicated algorithm has devolved requiring a multidisciplinary approach with institutional commitment and support. We performed a database review including pertinent articles exploring the multidisciplinary management of spinal metastatic disease. The wide variation in clinical presentation and tumor response to treatment necessitates a multidisciplinary approach that integrates the diagnosis and treatment of the cancer, symptom management, and rehabilitation for optimal care of patients with spinal metastases. Advances in the field of radiology have led to earlier and more focused diagnosis of spinal metastasis and acts to guide therapy. Advances in surgical techniques, neurophysiologic monitoring, and anesthetic expertise have allowed surgeons to perform more extensive procedures leading to improved outcomes and reduced morbidity. Radiation oncology input that is essential as external beam radiation therapy can provide significant pain relief. Non-operative measures may include bisphosphonate infusions, management of complications (e.g. hypercalcemia of malignancy), monoclonal antibody infusions, and chemotherapy if indicated in the treatment of the primary malignancy. Input from psychology services is necessary to address the biopsychosocial ramifications of spinal metastasis. Allied health professionals in the form of physiotherapists, social workers, and dieticians also contribute in maximizing patients' quality of life and well-being.

Scoliosis and the Social Media: Facebook as a Means of Information Exchange.

BACKGROUND CONTEXT: Over the last decade, the emergence of social networking websites such as Facebook have revolutionized information dissemination and broadened opportunities to engage in discussions. In particular, having been widely adopted in the younger generation, the use of this medium has become more prevalent in health disorders such as scoliosis in the adolescent population. However, the quality of information on Facebook is unregulated and variable, which may mislead patients in their decision making. PURPOSE: To document the various types of information available and assess the quality of information on Facebook discussion boards using recognized scoring systems. STUDY DESIGN: To evaluate the quality of information on the social network. PATIENT SAMPLE: A search for the keyword "scoliosis" on Facebook was performed and the first 100 pages generated were reviewed. OUTCOMES MEASURED: SCSS and DISCERN score. METHODS: Content analysis was performed on discussion boards and personal blogs. Two independent examiners evaluated each site according to scoliosis-specific content score (SCSS) and the DISCERN criteria, both previously used instruments to judge the quality of information on the Internet pertaining to scoliosis. The SCSS range from 0 to 32 (higher score better) and the DISCERN 16 to 80 (higher score better). RESULTS: Of the 100 sites reviewed, 33 were discussion boards and personal blogs. Of these, the overall average SCSS was 5.7 (SD 5.8, range 0-20) and the DISCERN was 22.5 (SD 7.6, range 16-45), indicating that using general scoring systems the quality of information provided was overall poor. CONCLUSION: Using recognized scoring systems to analyze Facebook pages used as discussion forums or blogs, we showed that the quality in general was poor. For modern practices to adapt to an era of information exchange via the social network, the orthopedic community should develop ways to incorporate the social media in future patient education.