Outcomes and patient perspectives of a novel virtual spinal referral pathway in a non-specialist centre.

INTRODUCTION: In Irish orthopaedic centres without dedicated spinal services, the care of patients is facilitated through tertiary referral centres in Dublin, Cork & Galway. The outpatient waiting list for elective spinal opinion remains lengthy and challenging. Previous practice in University Hospital Waterford (UHW) necessitated an assessment with a local non-spinal orthopaedic specialist following a GP referral, incurring up to a 2-year wait prior to subspecialist spinal referral. These patients subsequently incurred a further wait for an appointment at the tertiary referral centre. A novel virtual spine clinic in collaboration with the Mater Misericordiae University Hospital (MMUH) was developed to fast-track this process. AIMS AND METHODS: A retrospective study was performed to audit efficiency by assessing time to initial consultation and time to virtual consultation, treatment outcomes, and patient satisfaction using an adapted patient-satisfaction questionnaire (PSQ-18) and a semi-structured interview. This study reflected the unique nature of patient experience in this pathway. RESULTS: The median time from referral to being seen in an in-person rapid access physiotherapist combined orthopaedic clinic was 185 days. The median time from initial consultation to virtual consultation was 36 days. The median time interval from virtual consultation to intervention was 110 days. Twenty percent of patients underwent surgery, 14% were further seen in the MMUH outpatients, 7% managed with the trial of physiotherapy, 7% required no follow-up, and 50% planned for radiologically guided spinal injections. DISCUSSION AND CONCLUSION: This novel pathway is efficient for orthopaedic units without a dedicated spinal service. This can easily be replicated across other orthopaedic centres with minimal cost implications.

The impact of the SARS-CoV-2 pandemic on referral characteristics in a national tertiary spinal injuries unit.

BACKGROUND: The SARS-CoV-2 pandemic has had profound implications on healthcare institutions. AIMS: This study aims to assess and compare referral patterns during COVID-19 to corresponding dates for the preceding 3 years (2017-2019), in order to preemptively coordinate the logistics of the surgical unit for similar future experiences. METHODS: Retrospective review for our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic: (i) study period 1 (SP1) from 11 November 2020 to 08 June 2020 represents a national lockdown, and (ii) study period 2 (SP2) from 09 June 2020 to 09 September 2020 indicates an easing of restrictions. Both periods were compared to corresponding dates (CP1: 11 March-08 June and CP2 09 June-09 September) for the preceding 3 years (2017-2019). Data collected included age, gender, and mechanism of injury (MOI) for descriptive analyses. MOIs were categorised into disc disease, cyclist, road-traffic-accident (RTA), falls < 2 m, falls > 2 m, malignancy, sporting injuries, and miscellaneous. RESULTS: All MOI categories witnessed a reduction in referral numbers during SP1: disc disease (-29%), cyclist (-5%), RTAs (-66%), falls < 2 m (-39%), falls > 2 m (-17%), malignancy (-33%), sporting injuries (-100%), and miscellaneous (-58%). Four of 8 categories (RTAs, falls < 2 m, malignancy, miscellaneous) showed a trend towards return of pre-lockdown values during SP2. Two categories (disc disease, falls > 2 m) showed a further reduction (-34%, -27%) during SP2. One category (sporting injuries) portrayed a complete return to normal values during SP2 while a notable increase in cyclist-related referrals was witnessed (+ 63%) when compared with corresponding dates of previous years. CONCLUSION: Spinal injury continues to occur across almost all categories, albeit at considerably reduced numbers. RTAs and falls remained the most common MOI. Awareness needs to be drawn to the reduction of malignancy-related referrals to dissuade people with such symptoms from avoiding presentation to hospital over periods of social restrictions.

Anterior Versus Posterior Thoracic Discectomy: A Systematic Review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: The aim of this study was to systematically review the current evidence in the literature on thoracic discectomies, to compare the clinical outcomes, and to determine whether there is evidence to support the use of either the anterior or posterior approach. SUMMARY OF BACKGROUND DATA: Thoracic disc herniations (TDHs) often present with myelopathy, radiculopathy, or a combination of both. The posterior approach for thoracic discectomy has been associated with a lower complication rate, but no systematic review exists comparing the clinical outcomes. METHODS: MEDLINE, EMBASE, and The Cochrane Library databases were searched in accordance with the PRISMA guidelines for studies performing an anterior or posterior thoracic discectomy. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies checklist. The reported clinical outcomes were evaluated using risk ratio, with a P < 0.05 being considered statistically significant. RESULTS: Thirty-seven clinical studies with 1156 patients with 1300 TDHs were included in this review. There was no statistically significant difference in the total neurological improvement or neurological worsening using either an anterior approach or a posterior approach (P = 0.02812 and P = 0.5232, respectively). However, there was a statistically significant higher rate of total complications in the anterior approach (P = 0.0024). CONCLUSION: The anterior approach and posterior approach have been shown to be very similar in terms of neurological outcomes. Although the posterior approach was shown to have a lower rate of total complications, this was largely because of a decrease in minor respiratory complications seen in the anterior approach. The optimal approach may therefore be based on surgeon preference as well as patient factors, specifically cardiorespiratory with American Society of Anaesthesiologists grading. LEVEL OF EVIDENCE: 4.

Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity.

STUDY DESIGN: Observational cohort study. Retrospective review of prospectively collected outcomes data. OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy of minimally invasive (MIS) decompression for focal lumbar spinal stenosis (FLSS) in patients with and without deformity. SUMMARY OF BACKGROUND DATA: MIS, facet-preserving decompression has the potential of offering a significantly less morbid alternative to decompression and fusion in patients with leg dominant symptoms from degenerative spondylolisthesis and/or scoliosis. METHODS: Single surgeon, consecutive series (n=75), evaluated over 5 years. All patients had MIS lumbar laminoplasty (bilateral decompression from a unilateral approach) for FLSS (1-2 level). Patients had leg dominant, claudicant/radicular pain. Patients were divided into 4 groups: (A) stenosis with no deformity, n=22; (B) stenosis with spondylolisthesis only, n=25; (C) stenosis with scoliosis, n=16; and (D) stenosis combined with spondylolisthesis and scoliosis, n=12. The primary clinical outcome measures were the Oswestry Disability Index (ODI) and surgical revision rate. Preoperative and postoperative standing radiographs were assessed. RESULTS: The average age was 68 years (40-89) with a mean time from surgery of 36.5 months (18-68). Average clinical improvement in ODI was 49.5% to 23.9% [mean postoperative follow-up of 31.8 months (24-72): group A=mean of 34.6; B=28.9; C=32.7; D=30 months]. Incidence of preoperative grade I spondylolisthesis was 46%. Spondylolisthesis progression (mean=8.4%) occurred in 9 patients and 2 patients developed spondylolisthesis. Overall revision rate was 10% [repeat decompression alone (n=2) and decompression and fusion (n=6)]. Subgroup analysis of preoperative and postoperative ODI and revision rate revealed (A) 48% to 18.7%, 0%; (B) 48% to 24.6%, 4%; (C) 50.7% to 31.5%; 25%; and (D) 53% to 22%, 25%, respectively. The revision rate for patient with scoliosis (C+D) was significant (P=0.0035) compared with those without. Six of the 8 revised patients had a preoperative lateral (rotatory) listhesis (3 in C and 3 in D). CONCLUSION: MIS decompression alone for leg dominant symptoms is a clinically effective procedure in the majority of patients including those with degenerative spondylolisthesis or scoliosis. However, patients with scoliosis, particularly those with lateral listhesis, have a significantly higher revision rate that needs to be considered in operative decision-making.

Prophylactic stabilization of proximal femoral metastatic bone disease: reconstruction intramedullary nail fracture.

Pathological fracture is an unfortunate manifestation of metastatic bone disease and whenever possible, prophylactic stabilization is preferable to fixation of fracture. The Russell-Taylor reconstruction intramedullary nail (Smith & Nephew Richards, Inc., Memphis, Tennessee) provides a stable construct for the prophylactic management of impending pathological fracture. Implant failure with this system typically involves distal locking screws. Cases of proximal screw cut-out and pullout have been reported as has breakage of both proximal locking screws. We present a case of failure of the Russell-Taylor delta reconstruction nail implant, just distal to the point of insertion of the proximal locking screws.

Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center.

STUDY DESIGN: We performed a retrospective review of 48 cases of pyogenic spinal infection presenting over a 12-year period to the National Spinal Injuries Unit (NSIU) of the Republic of Ireland. The NSIU is the tertiary referral center for all adult spinal injuries and diseases of the spine warranting surgical intervention in the Republic of Ireland. OBJECTIVES: The objective of this study was to analyze the presentation, etiology, management, and outcome of nontuberculous pyogenic spinal infection in adults. SUMMARY OF BACKGROUND DATA: Pyogenic spinal infection encompasses a broad range of clinical entities, including spondylodiscitis, septic discitis, vertebral osteomyelitis, and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. METHODS: The medical records, radiologic imaging, and bacteriology results of 48 patients with pyogenic vertebral osteomyelitis from 1992 through 2004 were reviewed. The Hospital Inpatient Enquiry (HIPE) System and the NSIU Database were used to identify our study cohort. RESULTS: The average age of presentation was 59 years with an even distribution between males and females. Most patients (21 of 48) were symptomatic for between 2 and 6 weeks before presenting to hospital. The most frequently isolated pathogen was Staphylococcus aureus, in 23 of 48 cases (48%); 35 of 48 cases (73%) were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 13 of 48 cases (27%), surgical intervention was required because of neurologic compromise or mechanical instability. CONCLUSIONS: In the majority of cases, conservative management of pyogenic spinal infection with antibiotic therapy and spinal bracing is very successful. However, in a minority of cases, surgical intervention is warranted and referral to a specialist center is appropriate.

Fracture hematoma is a potent proinflammatory mediator of neutrophil function.

BACKGROUND: Patients with multiple skeletal injuries are susceptible to acute respiratory distress syndrome and multiple organ failure, which result from hyperactivation of the immune system. This study was designed to evaluate in vitro the proinflammatory properties of fracture hematoma (FH). METHODS: FH was isolated from patients undergoing emergent open reduction and internal fixation for isolated closed fractures. Neutrophils (PMNs), isolated from healthy volunteers, were exposed to the FH supernatant and activation was examined (CD11b and CD18 adhesion receptor expression and respiratory burst). PMN phagocytosis, apoptosis, and transmigration across an endothelial barrier were also assessed. RESULTS: FH increased PMN respiratory burst (control, 100; FH-treated, 186) and phagocytosis (control, 100; FH-treated, 172) but had no effect on adhesion receptor expression. Transendothelial migration of PMNs was unaffected, although FH was toxic to endothelial cells. In contrast, apoptosis of FH-treated PMNs was delayed (control, 46; FH-treated, 8). CONCLUSION: These effects, although beneficial at the site of injury in the context of antibactericidal function, may cause PMN-mediated tissue injury systemically.

N-acetylcysteine attenuates lung injury in a rodent model of fracture.

BACKGROUND: Neutrophil-mediated lung injury is a cause of significant morbidity and mortality in patients with multiple injuries. We have shown previously that fracture hematoma can activate neutrophils and is thus a putative mediator of the systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF) in those patients with severe skeletal trauma. Our aim was to establish a rodent model of fracture which caused lung injury and subsequently to administer a drug following fracture to attenuate the lung injury. The drug we chose was N-acetylcysteine, a potent antioxidant. ANIMALS AND METHODS: Adult Sprague-Dawley rats were assigned to 4 groups: (1) general anesthetic only, (2) general anesthetic with bilateral femur fractures and nailing, (3) general anesthetic and N-acetylcysteine, (4) general anesthetic with bilateral femur fractures and nailing and N-acetylcysteine after the injury (n = 6 in each group). The dose of N-acetylcysteine was 0.5 mg/kg which was given intraperitoneally after injury to the treated groups. The rats were killed 24 hours after injury and some parameters of lung injury were evaluated--i.e., bronchoalveolar lavage (BAL), lung tissue myeloperoxidase levels (MPO) and wet/dry ratios of lung tissue. The results were analyzed, using one-way analysis of variance. RESULTS: Bilateral femur fracture produced a significant lung injury, measured by increases in MPO (25-43 microg/g tissue) and BAL protein (460-605 microg/mL). This effect was attenuated by treatment with N-acetylcysteine (MPO 43-9 microg/mL, BAL protein 605-198 microg/mL). INTERPRETATION: N-acetyl cysteine, if given after skeletal trauma, is of potential therapeutic benefit, in preventing SIRS, ARDS and MOF.

The 90/90 pillow reduces blood loss after knee arthroplasty: a prospective randomized case control study.

Our goal was to evaluate the 90/90 pillow as an effective means of preventing blood loss after knee arthroplasty. We performed a prospective randomized case-control study on 40 patients undergoing knee arthroplasty. All patients were treated in a standard fashion, except for the use of the 90/90 pillow in one group. The 90/90 pillow flexes the knee to 90 degrees and is in situ for 24 hours after surgery. We measured blood loss at time points from 1 to 48 hours. Range of motion was assessed, as were analgesic requirements. Statistical analysis was performed on our results. We found a statistically significant reduction in blood loss without compromising range of motion. We advocate the 90/90 pillow after all knee arthroplasties.

Anterior lumbar interbody fusion with processed sea coral (coralline hydroxyapatite) as part of a circumferential fusion.

STUDY DESIGN: A retrospective review of 20 patients undergoing circumferential lumbar fusion with coralline hydroxyapatite blocks anteriorly and autograft with transpedicular or translaminar facet screw fixation posteriorly. OBJECTIVES: To examine the efficacy of coralline hydroxyapatite as a bone graft substitute for anterior lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: Autograft is the gold standard for bone grafting in the anterior lumbar spine. Harvesting bone from the iliac crest leads to significant postoperative pain and morbidity. Femoral ring allograft is a widely used alternative to autograft but has some inherent problems. Coralline hydroxyapatite was shown to be 100% successful for anterior cervical fusion when combined with rigid plating. METHODS: A retrospective review of 20 patients with low back pain and indicated for surgical intervention. A circumferential instrumented fusion was performed with coralline hydroxyapatite blocks anteriorly and transpedicular or translaminar facet fixation and autograft posteriorly. All patients reached a minimum 3-year clinical and radiologic follow-up. RESULTS: Radiographic follow-up yielded a solid arthrodesis rate of 93.8% by level (30 of 32 disc spaces) and 90% by patient (18 of 20). Clinical follow-up generated a mean pain reduction of 61.8% with clinical success demonstrated in 80% (16 of 20) of all patients who reported good or excellent pain relief. Eight of 12 (66.7%) patients employed before surgery returned to work in some capacity. CONCLUSIONS: Coralline hydroxyapatite is a practicable anterior lumbar interbody fusion alternative to autograft and allograft as part of a circumferential fusion with rigid posterior fixation. It is not recommended for stand-alone anterior lumbar interbody fusion without further study.

Anterior lumbar interbody fusion with titanium mesh cages, coralline hydroxyapatite, and demineralized bone matrix as part of a circumferential fusion.

BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) has become one of the primary choices for eliminating motion between vertebral segments in patients with severe discogenic pain and other lumbar pathologies. Autograft is the gold standard for spinal fusion. However, multiple authors have reported complication and morbidity rates associated with iliac crest harvesting to be as high as 25%. Drawbacks to the use of allograft in the anterior column include slower incorporation rates, the possibility for disease transmission, increasing cost resulting from stringent processing and unavailability on a worldwide basis resulting from religious and economic concerns. PURPOSE: To determine the clinical and arthrodesis efficacy of coralline hydroxyapatite as an osteoconductive bone graft substitute in the anterior lumbar spine using a titanium mesh cage. STUDY DESIGN: A series of 50 patients returning for long-term prospective follow-up, implanted with titanium mesh cages filled with coralline hydroxyapatite and demineralized bone matrix for ALIF as part of a circumferential fusion. PATIENT SAMPLE: Long-term clinical and radiographic follow-up were examined for the first 50 patients undergoing this technique by one surgeon. OUTCOME MEASURES: Pain was measured with a visual analog scale and function was measured with the Oswestry Disability Index. METHODS: All 50 patients underwent successful ALIF with titanium mesh cages, coralline hydroxyapatite and demineralized bone matrix, as well as an autologous posterolateral fusion with rigid posterior instrumentation. Patients filled out follow-up questionnaires and appropriate radiographs were taken. RESULTS: A solid fusion rate of 96% was achieved. Mean pain decrease was 60% overall. A total of 70% of all patients either returned to work or to full home activities at a mean of 8 months after surgery. Ninety percent felt the surgery was successful. CONCLUSIONS: The combination of titanium mesh cages, coralline hydroxyapatite and demineralized bone matrix is effective for anterior interbody fusion of the lumbar spine when used as part of a rigidly instrumented circumferential fusion.