Lumbosacral fusion using the Boucher technique in combination with a posterolateral bone graft.

This study evaluates the clinical and radiological results of using the facet screw fixation technique described by Boucher in combination with a posterolateral fusion rather than a posterior fusion for symptomatic degenerative disease of the lumbosacral junction. It is a retrospective review of 38 consecutive patients with an average follow-up of 28 months. Radiologically, all patients had a solid fusion. Clinically, 23 patients (60%) had excellent results, 11 patients (29%) good results, 3 patients (8%) fair results and 1 patient (3%) had a poor result. There were no neurological complications. The findings support the view that the Boucher technique of facet joint fixation in combination with a posterolateral fusion is a safe and effective method of dealing with chronic symptoms relating to degenerative changes at the lumbosacral junction. The authors stress the importance of patient selection and attention to operative technique if the clinical results are to correlate with the results of fusion.

Triage of back pain by physiotherapists in orthopaedic clinics.

In 1994 we described a system whereby certain patients with back pain, on referral to an orthopaedic clinic, were seen first by a physiotherapist who referred on only the problem cases and those in need of surgery ('triage'). This practice has grown rapidly but there have been difficulties. To clarify these we have carried out a postal questionnaire. The results reveal similar practices in most centres but some discrepancies that are cause for concern. These relate to the workload of the physiotherapist, informed consent, supervision and accountability, the type of cases seen and not least the stresses on the physiotherapist. We believe the triage system has many benefits, but if it is not to be derailed the issues of concern must be addressed and the posts properly structured.

Initial assessment and follow-up by a physiotherapist of patients with back pain referred to a spinal clinic.

To reduce waiting times and costs, a specially trained physiotherapist was employed to review 100 patients with back pain referred by general practitioners (GPs) to a spinal clinic; 78% proved to have a spinal disorder. Only 24% of the original referrals needed to see the surgeon, with 76% being successfully managed by the physiotherapist. Six per cent of referrals were deemed inappropriate and 16% of patients failed to attend. To evaluate the physio-therapist's assessments each case was discussed with the consultant surgeon, and the appropriateness of the management of each patient was similarly investigated. With appropriate training and a good working relationship with the surgeon, a chartered physiotherapist can successfully screen patients in a low back pain clinic, such that the efficiency of the unit is improved by improving the throughput whilst maintaining the same standard of care.

Stability of the lumbar spine and method of instrumentation.

We have carried out a biomechanical study to investigate the effect on flexion, extension, and rotation of seven systems of fixation on five cadaveric lumbar spines. Pedicle fixation proved the most effective method to restrict these movements. Facet screw fixation was also successful. Harrington distraction rods, the Hartshill rectangle and the Luque technique, although restricting slight flexion and extension, exerted little control over rotation. We conclude that pedicular fixation and facet joint fixation provide the greatest overall stability and might, therefore, be the best systems to consider for multilevel fusions in the lumbosacral region.

Low back pain with fracture of the pedicle and contralateral spondylolysis. A technique of surgical management.

We present a 26-year-old athlete with severe low back pain associated with a fracture of a lumbar pedicle and contralateral spondylolysis. The difficulties of diagnosis are discussed together with the subject of segmental pain referral. A technique of operative management is described involving instrumentation of the symptomatic level alone.

The rib deformity in adolescent idiopathic scoliosis. A prospective study to evaluate changes after Harrington distraction and posterior fusion.

A prospective study to investigate changes in the rib hump or rib deformity after correction of the lateral curvature in adolescent idiopathic scoliosis is reported. The operative treatment for 47 patients was by a Harrington distraction rod and posterior fusion. Before operation and at follow-up, measurements of the Cobb angle, of vertebral rotation, and of the rib deformity were taken. Despite operative correction of the lateral curve, there was a progression of the rib deformity in 64% of the cases after four years. Correction of the lateral curve may thus have no effect on vertebral rotation and cannot be guaranteed to effect a permanent reduction of the rib hump.

Radical excision of an osteoblastoma of the cervical spine. A combined anterior and posterior approach.

We report and discuss a combined anterior, anterolateral and posterior approach to the lower cervical spine. This was used for the radical resection of a recurrent osteoblastoma which involved the lateral mass, pedicle, and lamina of the sixth cervical vertebra.

Discogenic pain persisting despite solid posterior fusion.

Persistent back pain in the presence of an intact posterior fusion is commonly seen and is often regarded as being psychogenic in origin. This paper discusses five patients, all of whom were chronically disabled by such pain; all five had a confirmed posterior and/or lateral fusion. In each case lateral discography identified the disc within the fused segment as the source of symptoms and pain relief was obtained with an anterior interbody fusion. This source of pain should be considered as a possibility in similar cases of failed back surgery.

Bone necrosis and urinary hydroxyproline excretion in rabbits.

1. Aseptic necrosis of bone is a serious chronic complication of deep-sea diving and compressed-air work. 2. The changes to the bone which occur in this condition take time to develop to the stage where they cause the radiographic signs of bone necrosis, and consequently there is a delay of some months between the causal incident and the first diagnosis by radiography. 3. As a possible method for the earlier detection of bone necrosis the 24 h urinary excretion of hydroxyproline was measured over a period before and after experimental production of bone necrosis in rabbits by the intra-arterial injection of glass microspheres. 4. Total hydroxyproline excretion rose significantly within a few days of the injection in those rabbits in which there was later shown to be historical evidence of bone necrosis. This rise occurred long before there was any radiographic changes. 5. It is suggested that measurements of urinary hydroxyproline might be used to give an early indication of bone necrosis in man.

Aseptic necrosis of bone in a compressed air worker.

This paper reports a detailed examination of three lesions of aseptic necrosis of bone occurring in a man who had worked in compressed air eleven years previously. Although two of the lesions were juxta-articular, in neither had the bone collapsed. Histology of only one similar lesion is reported in the literature (McCallum et al. 1966). Necropsy material is considered, together with radiographs and bone scans of the same lesions taken four years earlier. Similar changes have been shown to occur in commercial divers. On the evidence of this case it becomes clear that radiography is limited in its use and that bone scans as an indicator of repair may be open to misinterpretation. There may be a place for operation before the onset of symptoms in these cases of aseptic bone necrosis.