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2 BRITSPINE 2014 www.britspine.com BritSpine 2014 Warwick Arts Centre • The University of Warwick April 1st - 4th 2014 The University of Warwick Warwick Arts Centre BritSpine 2014 The 8th BritSpine Conference is organised by United Kingdom Spine Societies Board (UKSSB) in association with the: Society for Back Pain Research (SBPR) British Scoliosis Society (BSS) British Association of Spine Surgeons (BASS) United Kingdom Spine Societies Board www.ukssb.com The UKSSB was formed in 2012 and is an organisation composed of 3 national spinal societies. The object of the UKSSB is to promote the development of treatment of spinal disorders through education, study and research for the benefit of the public and the United Kingdom. Membership of the UKSSB comprises the Chair, Honorary Treasurer and nominated Officers of the SBPR, BSS, BASS, British Orthopaedic Association (BOA) and the Society of British Neurological Surgeons (SBNS). Society for Back Pain Research (SBPR) www.sbpr.info The Society for Back Pain Research was formed in 1971 to promote the study of all clinical and scientific aspects of spinal pain, including the neck and to encourage research into its causes, treatment and prevention. There are now almost 150 members of the Society, from a wide range of disciplines, including clinicians such as orthopaedic surgeons, rheumatologists, neurologists, general practitioners, basic scientists including biochemists, bio-engineers, anatomists and epidemiologists, as well as various other practitioners including physiotherapists, osteopaths & chiropractors. British Scoliosis Society (BSS) www.britscoliosissoc.org.uk The British Scoliosis Society represents surgeons, healthcare workers and researchers interested in the nature and treatment of scoliosis and complex spine disorders. The principal object of the Society is to provide a forum for the study of the origin, natural history and treatment of spinal deformities. British Association of Spine Surgeons (BASS) www.spinesurgeons.ac.uk BASS actively promotes the study of spinal disorders with particular attention to the surgical treatment of spinal disease and disorders. Designed and printed by Warwick Print, www.warwickprint.co.uk Part of the commerical arm of the University of Warwick Charity No 1150365 Company Limited by Guarantee No 8156883 Charity No 294272

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Page 1: BritSpine 2014 -  · PDF filefeast followed by Bollywood dancing! ... together with the opportunity for developing professional contacts and friendship. It ... BritSpine 2014

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www.britspine.com

BritSpine 2014Warwick Arts Centre • The University of Warwick

April 1st - 4th 2014

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The 8th BritSpine Conference is organised by United Kingdom

Spine Societies Board (UKSSB) in association with the:

Society for Back Pain Research (SBPR)

British Scoliosis Society (BSS)

British Association of Spine Surgeons (BASS)

United Kingdom Spine Societies Board

www.ukssb.com

The UKSSB was formed in 2012 and is an organisation composed

of 3 national spinal societies. The object of the UKSSB is to

promote the development of treatment of spinal disorders

through education, study and research for the benefi t of the

public and the United Kingdom. Membership of the UKSSB

comprises the Chair, Honorary Treasurer and nominated Offi cers

of the SBPR, BSS, BASS, British Orthopaedic Association (BOA)

and the Society of British Neurological Surgeons (SBNS).

Society for Back Pain Research (SBPR)

www.sbpr.info

The Society for Back Pain Research was formed in 1971 to promote

the study of all clinical and scientifi c aspects of spinal pain,

including the neck and to encourage research into its causes,

treatment and prevention. There are now almost 150 members

of the Society, from a wide range of disciplines, including

clinicians such as orthopaedic surgeons, rheumatologists,

neurologists, general practitioners, basic scientists including

biochemists, bio-engineers, anatomists and epidemiologists, as

well as various other practitioners including physiotherapists,

osteopaths & chiropractors.

British Scoliosis Society (BSS)

www.britscoliosissoc.org.uk

The British Scoliosis Society represents surgeons, healthcare

workers and researchers interested in the nature and treatment

of scoliosis and complex spine disorders. The principal object

of the Society is to provide a forum for the study of the origin,

natural history and treatment of spinal deformities.

British Association of Spine Surgeons (BASS)

www.spinesurgeons.ac.uk

BASS actively promotes the study of spinal disorders with

particular attention to the surgical treatment of spinal disease

and disorders.

Designed and printed by Warwick Print, www.warwickprint.co.uk

Part of the commerical arm of the University of Warwick

Charity No 1150365 Company Limited by Guarantee No 8156883

Charity No 294272

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4 5BRITSPINE 2014BRITSPINE 2014

Contents

Introduction to BritSpine 3

Welcome Messages 4-5

Statement from UKSSB Chair 6

Local Organising Committee and Administrative Staff 7

Useful information 8-9

The University of Warwick Campus Map 10

Places of Interest 11-12

Local Restaurants and Hotels 13

Social Events 14

International Faculty 15

Industry Faculty 16

National Faculty 17-18

Programme Outline and Key 19-20

Programme Tue 1 April 21

Programme Wed 2 April 22-24

Programme Thu 3 April 25-27

Programme Fri 4 April 28-29

Programme Patients’ Afternoon Fri 4 April 31-32

Presentations - Oral Lumbar Degenerative 33-34

Presentations - Oral BASS Session 1 35-37

Keynote Lecture 1 37

Presentations - Oral Tumour 1 38-39

Presentations - Oral BASS Session 2 40-41

Keynote Lecture 2 42

Presentations - Oral Tumour 2 43-44

Presentations - Oral BASS Session 3 45-46

Presentations - Oral BSS Session 1 47-49

Presentations - Oral SBPR Session 1 49-51

Keynote Lecture 3 52

Keynote Lecture 4 52

Presentations - Oral SBPR Session 2 53-55

Presentations - Oral BSS Session 2 55-58

Keynote Lecture 5 58

Keynote Lecture 6 58

Presentations - Special Posters: Surgical 59-63

Presentations - Special Posters: Non-Surgical 64-68

Keynote Lecture 7 69

Presentations - Posters 70-84

Posters & Exhibition Floor Plan: Butterworth Hall 85

Posters & Exhibition Floor Plan: Mead Gallery 86

Exhibitors’ Profi les 87-94

Exhibitors’ Names & Stand Numbers 96

Dates for your diary 98

Notes 99-101

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6 7BRITSPINE 2014BRITSPINE 2014

2012 Gateshead

2010 Liverpool

2008 Belfast

2006 Cardiff

2004 Nottingham

2002 Birmingham

1999 Manchester

Welcome message from BritSpine 2014 Local Organising Committee

Dear Colleagues

It gives us great pleasure to welcome all delegates to the 8th BritSpine Conference being held at The University of Warwick.

We would like to extend a special welcome to our overseas delegates and keynote speakers, who we are sure will provide a stimulating and diverse contribution to the debates and topics during the conference.

This is the fi rst BritSpine meeting to include a whole day cadaveric workshop for dedicated spinal trainees, which takes place on Tuesday 1st April, the day before the main scientifi c meeting, and we are grateful to Depuy Synthes, Stryker Spine, K2M, Globus Medical and NuVasive for making this possible.

This is also the fi rst of such meetings to be a fully residential one on an academic facility and to also include a patient interactive session on the last afternoon of the meeting. We are aware of the fi nancial constraints on our non-surgical allied healthcare professionals and have therefore encouraged them to attend on the last day at a signifi cantly incentivised rate.

We have, taken care to work in partnership with the Trade Exhibitors as we all realise that the future is in partnership between clinicians and the organisations that provide us with the tools to develop spinal treatments. We would, therefore, encourage all delegates to visit all the trade stands and break the ice at the Industry speed dating.

On Thursday evening the Gala Dinner is being held at the stunning setting of Stoneleigh Abbey, originally the site of a Cistercian monastery, later acquired by Sir Thomas Leigh, the Lord Mayor of London, in 1558. The evening will be in the form of an informal Indian feast followed by Bollywood dancing!

The guest speaker will be the internationally acclaimed water colour artist Professor Peter Welton, D. Litt, who has been commissioned by, amongst others, HRH Queen Elizabeth II, The Duke of Gloucester and The Maharane of Udaipur.

Finally we would like to thank Jane Gray of Warwick Conferences, Julie Archer of Archer Yates Associates and Julia Bloomfi eld of UKSSB and all their colleagues for their signifi cant contribution in facilitating this meeting.

8th BritSpine

Nick Birch Nilam Shergill Robert Sneath

The fi rst combined meeting of the British Spinal Societies took place in Manchester in 1999. This achieved the objective of bringing together, for the fi rst time, many of those with an interest in research and management of the spine and its disorders.

Important cross-fertilisation of ideas occurred, together with the opportunity for developing professional contacts and friendship. It was concluded that such meetings should be repeated, in the initial instance, at three yearly intervals, but after Birmingham in 2002 it became biennial.

BritSpine conferences are held over 3 days and involve the presentation of the latest spinal surgery techniques, instructional sessions and free papers. The meeting attracts over 500 delegates.

Previous BritSpine conferences:

Introduction to BritSpine

If you would like to receive more information about SBPR (www.sbpr.info), BSS (www.britscoliosissoc.org.uk) and BASS (www.spinesurgeons.ac.uk), please visit the registration area, the societies’ websites or the UKSSB website www.ukssb.com.

Archer Yates Associates Ltd » Tel: +44 (0)1608 659900 » www.archer-yates.co.uk

We are a leading, professionally recognised event management company. With over 30 years experience of organising and managing events, from conceptionright through to completion, on all scales from anexecutive board meeting to large annual conferences.

Let us help you create a memorable event that reflects and exceeds your targets and expectations. We can research, plan, deliver and evaluate every element from travel to destination, hotel and entertainmentto technical production and booking management.

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take the strain.

For a no obligation chat and to help you develop your ideas further, contact our friendly team on 01608 659900 or email Managing Director Julie Archer at [email protected]

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8 9BRITSPINE 2014BRITSPINE 2014

Welcome message from Jeremy Fairbank

Chair – United Kingdom Spine Societies Board (UKSSB)

Dear Colleagues

Welcome to BritSpine 2014. This is the 8th BritSpine meeting and is being sponsored by the UKSSB, which is formed of the 3 main UK spine societies - Society for Back Pain Research, British Scoliosis Society and the British Association of Spine Surgeons.

Every 2 years this meeting has grown in size and scope. This year Nick Birch, Nilam Shergill, Robert Sneath and their team have done us proud with a thoughtful and wide-ranging programme in a perfect venue.

We hope that you enjoy the meeting and take away new knowledge and expertise. Please tell us how it can be done even better next time round. Please feel free to speak with me. We value your feedback.

Welcome message from John O’Dowd

President – Society for Back Pain Research

Dear Colleagues

I would like to add a warm welcome to BritSpine at The University of Warwick from the Society for Back Pain Research.

We are proud to participate in these biennial meetings of the spinal community in the UK and are delighted at the progressive increase in the scientifi c content over the years.

I congratulate all the presenters on the very high quality of the podium and poster presentations this year. These meetings are a unique opportunity for our diff erent communities to network and I hope you go home challenged afresh to look at the principles and science that underpin your daily clinical practice.

Welcome message from Ian Nelson

President – British Scoliosis Society

Dear Colleagues

Welcome to BritSpine 2014 from the British Scoliosis Society. We are grateful to the organising committee, our industry sponsors, our guest speakers and the delegates for their participation in this increasingly important meeting in the busy spine calendar.

We congratulate those colleagues who have had presentations and posters accepted for the meeting and thank them for their scientifi c endeavours.

We look forward to input from all UK orthopaedic and neurosurgical spine surgeons, our spine allied healthcare professionals and the spine scientifi c research community in the UK as to the future direction of this meeting and the working relationship between the three societies as fostered by the UKSSB.

Welcome message from Adrian Casey

President – British Association of Spine Surgeons

Dear Colleagues

Welcome to BritSpine, the biennial conference where the 3 British spine societies come together for their academic meeting. We are grateful to our local hosts and the UKSSB for their hard work in putting this major event together.

The British Association of Spine Surgeons will be holding its Annual General Meeting on Thursday, 3rd April. There will be several important issues discussed, along with voting for posts within the Executive.

There will also be updates on the British Spine Registry, education and professional matters. I hope that as many of our members as possible can attend.

We look forward to welcoming you in person.

UKSSB Chairman’s Statement to BritSpine AGM

Dear Spine Societies’ Members

It has been a busy and interesting time since we last met at the Newcastle AGM in 2012. This statement is for discussion at the 2nd AGM in Warwick.

Role of UKSSB

The UKSSB has two main functions:

1. To ensure that BritSpine is correctly organised and fi nanced.2. To act as a mechanism of communication, and action for,

matters that concern the membership of the three spine societies, the BOA and SBNS. It uses the profi ts of BritSpine to do this and also to ensure that future BritSpines have a viable fi nancial infrastructure and organisation.

The UKSSB is being incorporated as a Company Limited by Guarantee to achieve these aims.

The Board consists of the Presidents and Secretaries of SBPR, BSS and BASS, representatives of SBNS and BOA, a Chairman and a Treasurer.

BritSpine 2014

I am very grateful for all the work that Nick Birch, Nilam Shergill, Robert Sneath and their team have put into making this meeting happen. It is no trivial matter to organise meetings of this size and complexity and especially to keep them in the black. We owe them all great thanks.

BritSpine 2016

This will be hosted by Nas Qureshi and his colleagues in Nottingham.

BritSpine 2018

We would like to hold this in London. John O’Dowd is leading a team to identify a venue and come up with a fi nancial plan.

PCPIE Meeting (PCPIE = Patient, Carer, Public Involvement and Engagement)

Space has been made available on the Friday afternoon of this BritSpine for a PCPIE meeting and this has spurred us into action. Public involvement is a critical aspect of the delivery of healthcare in the UK. It is also essential for research delivery, both as a really important input to identifying research topics, ethics, trial design, etc, but also for fund raising.

There are many aspects of what we, as medical professionals, do that can benefi t from public involvement. However, this also means we need clinical engagement. I hope that many of you can make time to attend this session, which is at no cost, because it has been funded by the UKSSB.

The Royal College of Surgeons of England consider this a worthwhile CPD activity and have accredited it with 3 hours of CPD points in addition to the 15 hours for the main part of BritSpine 2014.

If this fi rst PCPIE meeting is a success, we would hope it will become a regular part of future BritSpines.

eSpine

eSpine is an educational resource based on the teaching package eBrain. It is funded through the UKSSB via its Education and Training Initiative and is being launched at this meeting. It will be accessible to members of all the spine societies and its content depends on contributions from the whole membership. We expect it to continue to develop as a resource.

UKSSB Secretariat

Julia Bloomfi eld was appointed Executive Assistant to the UKSSB two years ago and is one of the main reasons that the Board has been able to develop. She has worked hard to make BritSpine 2014 a success. She also contributed to the success of last year’s BASS meeting in a supportive role to Archer Yates Associates.

For the fi rst time at any of the societies’ meetings, Survey Monkey was introduced as a means of registering for a CPD certifi cate. Julia set this up for last year’s BSS meeting as a trial venture and this proved to be successful. She has also set up Survey Monkey for this BritSpine and you are reminded that you must complete the survey in order to receive a CPD certifi cate. Full details are in your delegate bag and can also be found at the registration area. The Survey Monkey facility has also been used by societies for their own initiatives.

One major piece of work has been to rationalise the membership lists of all 3 societies. Our fully paid up membership now stands at:

● SBPR - 135● BSS - 123● BASS - 370

Website (www.ukssb.com)

This has developed over the last two years to provide up-to-date information on future meetings, postings of relevance to the spine community, such as the Spine Task Force Report, communications from NICE and comments on infection as a cause of back pain; a list of spine societies around the world; contact list for companies active in the spine fi eld, etc. We now have a website for all BritSpine meetings past and future at www.britspine.com.

National Clinical Director and National Commissioning

The UKSSB, its website and contact list is used by Professor Charles Greenough, who is the National Clinical Director for Spinal Disorders within NHS England, as a means of contacting the whole spine community. One of his main activities has been the Department of Health Pathfi nder Project to provide a structure for back pain delivery.

UKSSB Constitution

Setting up and running the UKSSB has made us think carefully about what we want our spine societies to do. We shall discuss again the way the societies work at the end of this meeting.

The future for spinal care in the UK is in the hands of the membership of the three societies and it is vital that as many members as possible attend the AGM on Thursday afternoon at the Warwick Arts Centre.

Professor Jeremy Fairbank

UKSSB ChairApril 2014

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10 11BRITSPINE 2014BRITSPINE 2014

The BritSpine team is dedicated to ensuring that the conference and exhibition runs smoothly and that your attendance at the event is both educational and enjoyable.

If you have any problems or require any assistance, we would be delighted to help you. Please visit us at the registration area.

The organisers cannot accept responsibility for any information in this guide that may be incorrect or accept any responsibility for programme changes.

Please note that the distribution of promotional material except by exhibitors on their stands is strictly prohibited.

Local Organising Committee

Administrative Staff

Nick BirchConsultant Spinal SurgeonWoodland Hospital, Kettering

Julie ArcherEvent ManagementArcher Yates Associates LtdOxford

Nilam ShergillConsultant Spinal SurgeonUniversity Hospital Coventry & Warwickshire

Julia Bloomfi eldExecutive AssistantUnited Kingdom Spine Societies Board, RCS London

Robert SneathConsultant Spinal SurgeonUniversity Hospital Coventry & Warwickshire

Useful Information For Delegates

Abstracts & Posters

Abstracts will be published in a special supplement of the European Spine Journal which is in your delegate bag. All oral, special posters and poster presentations are also included within this programme.

Posters will be on display within the exhibition throughout the conference and will be taken down at 12.30 on Friday, 4th April.

Prizes will be awarded as follows:

• Best Surgical Podium Presentation at BritSpine 2014 (K2M)

• Best Non-Surgical Podium Presentation at BritSpine 2014 (Medtronic)

• Best Surgical Poster Presentation at BritSpine 2014 (Stryker)

• Best Non-Surgical Poster Presentation at BritSpine 2014 (Zeiss)

• Best Presentation by a Surgical Trainee at BritSpine 2014 (Depuy Synthes)

• Best Presentation by a Non-Surgical Healthcare Professional at BritSpine 2014 (Globus)

• Presentation judged to be the Most Innovative at BritSpine 2014 (NuVasive)

• Presidents’ Prize for Outstanding Scientifi c Contribution to BritSpine 2014 (Macromed)

Attendance Certifi cates – CPD/CME

This conference has been accredited by the Royal College of Surgeons of England. It has been awarded 6 CPD/CME points for each of Wednesday, Thursday and Friday, making a grand total of 18 points for the whole event. An Attendance/CPD/CME Certifi cate will not be provided at the conclusion of this event. The only method of obtaining a certifi cate is online via Survey Monkey as outlined in the handout in your delegate bag. Please note that security protection on NHS computers may prevent access to the Survey Monkey link. It is, therefore, advisable to complete the survey on a personal computer. The electronic certifi cate can be included in CPD/CME portfolios as proof of attendance at the meeting and, according to current guidance, should be accompanied by notes on how the meeting was of benefi t to career development or current practice.

Audiovisual/Speakers’ Room

The Audiovisual Speakers’ Room is situated in the National Grid Room. Presenters should register their attendance prior to the start of the session in which they are speaking. The opening times are 08.00 on Wednesday, 2nd-Friday, 4th April.

Badges and security

For security purposes all delegates, accompanying persons and exhibitors MUST ensure they are wearing the offi cial BritSpine name badge AT ALL TIMES whilst in the Warwick Arts Centre and social events. There will be specifi c colour-coding to distinguish faculty, delegates and conference organisers. Further details will be advertised at the registration area.

Business Centre

For those participants who are resident in either Radcliff e or Scarman, a business centre is available to use on the ground fl oor of each venue. For those who are resident on the main Conference Park, computer terminals, printers and photocopiers are available in the Conference Reception located on the ground fl oor of the Students Union.

Cancellations

Delegates who cancel their booking will not be entitled to a refund of fees already paid.

Car Parking

Once you arrive on campus please look out for the green Warwick Conferences signage to direct you to the car parks and conference venues.

Complimentary car parking is available for conference delegates in the allocated car parks on campus (7, 8, 8a and 15). On entering the car park, take a token from the machine which you can then validate at Conference Reception. Please note that in CP8a and 8 there is no token machine, but conference delegates are permitted to park in these car parks without the need to pay and display. Disabled parking spaces are available close to the entrance of main buildings.

As a university campus, from time to time these car parks become full. When this happens alternative parking will be available which you will be directed to.

Participants who are resident in Radcliff e or Scarman can use the appropriate venues “residents only” car park.

Cash machine

There are branches of Barclays and Santander Banks on campus. Both have cash machines in, or just outside, the Students Union Building (directly next to the Rootes Building).

Catering

Tea, coff ee and biscuits will be served in Butterworth Hall and the Mead Gallery (trade exhibition areas) during the morning and afternoon conference breaks.

Lunch will be provided to delegates, faculty, organisers and trade delegates who have appropriate badges. Please note that only one lunch per badge is available on each day. Special dietary requirements will be catered for if requested in advance.

In addition, lunches will be available in “grab bags“ to be picked up from Butterworth Hall and Mead Gallery for those delegates attending lunchtime workshops.

Cloakroom

There is a manned cloakroom located within the Arts Centre and is open from 08.00-18.00 Wednesday-Friday. Items may be deposited at owners’ risk.

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12 13BRITSPINE 2014BRITSPINE 2014

Exhibition

Delegates are encouraged to visit the exhibition which is located in Butterworth Hall and Mead Gallery. The exhibition is open throughout the conference, but will close at 12.30 on Friday, 4th April. Information on exhibitors and their products can be found at the back of this guide.

Fire Regulations

You will be advised if there are any planned fi re alarm tests or evacuation drills during this event. If the alarm sounds at any other time then a full evacuation is necessary. There is information in each meeting room regarding the fi re procedure and other useful information which all speakers or presenters should read to delegates before starting the session. You will be directed to specifi ed fi re assembly points by university staff who will monitor and attend any alarm in progress. Do not re-enter the building until told to do so by university security staff .

First Aid

If fi rst-aid is required, please speak to a member of the University of Warwick staff who will contact a fi rst-aider. All calls for “emergency services” should be made to University Security Services, 24 hours a day. This will ensure that the Emergency Services can be escorted to the scene of the emergency as quickly as possible. To do this dial 22222 from any “internal” telephone or 024 7652 2222 from a mobile phone.

Internet Access

There is Internet access throughout the venue and accommodation. Delegates will be issued with usernames and passwords in order to access Wi-Fi.

Local information

The Warwick Arts Centre has a selection of literature covering local information, attractions and events. A selection of local attractions are highlighted within this guide.

Message Board

A message board is located in the registration area. This is for use by delegates to make contact with other delegates. It should not be used for promotional purposes such as displaying literature about other events.

Mobile Telephones/Pagers

Delegates must ensure that mobile telephones and pagers are are switched off or in silent mode during all sessions.

People with Disabilities

Please note that mobility scooters are available if required. However, prior notice is preferred in order that scooters can be charged. If assistance is required throughout the conference, delegates are advised to speak with one of the Conference Assistants assigned to the event. They can be recognised by their uniform of black trousers and burgundy shirt.

Photography

Photography or video recording are not permitted during sessions except by the offi cial conference photographer and video fi lm maker.

Prayer Room

A Chaplaincy is situated on the main campus for multiple denominations and is available for use throughout the conference. To gain access to the Chaplaincy, please ask at Conference Reception for details.

Recycling

Recycling bins have been provided throughout the venue to recycle plastic and paper, including unwanted abstract books and programmes. Please use these whenever possible and help reduce the environmental impact of the conference. Unwanted delegate bags, etc can be recycled via the registration area.

Registration Area

The registration area is located on the Mezzanine fl oor in the Warwick Arts Centre and is open throughout the conference. Delegates are asked to visit the registration area should any queries arise concerning the event. The opening times are 11.30-18.30 Tuesday, 08.00-18.00 Wednesday and Thursday and 08.00-16.00 Friday.

Registration On-Site

On-site registration will be through www.britspine.com and can be accessed through personal laptops/pad devices/smartphones using the on-site Wi-Fi (code available at the registration desk) or through laptops that will be available in the registration area.

On-site registration will not guarantee accommodation, but if any rooms are available it will be possible to provide residential registration. On-site payment can be made by credit card (Visa/MasterCard) or a debit card. No other forms of payment will be accepted.

Venue

Warwick Arts CentreUniversity of WarwickGibbet Hill RoadCoventryWarwickshire CV4 7AL

The University of Warwick Campus Map

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14 15BRITSPINE 2014BRITSPINE 2014

Places of Interest

Welcome to Coventry and Warwickshire

Warwickshire’s County Town is world-famous for its magnifi cent castle and historic charm. There are many attractions to visit, beautiful parks and gardens and buildings of outstanding quality from every period of the last thousand years. Warwick’s mainly independent businesses off er an enticing blend of the old and the new - from gift shops, antique centres and traditional tea rooms to trendy boutiques, art galleries and fi ne restaurants. Warwick is blessed with beautiful parks and gardens all within easy walking distance of the town centre. Warwick has a good selection of quality independent hotels and guest houses in the town centre, a few larger chain hotels on the edge of town and some beautiful properties in the surrounding countryside. The following is a selection of places of interest in and around Warwickshire.

Collegiate Church of St Mary

St Mary’s Collegiate Church dominates the overall view of the centre of Warwick with its imposing tower, rebuilt along with much of the church in 1704 by Sir William Wilson after the Great Fire of Warwick. There has been a church on the site since Saxon times, but the Saxon church was rebuilt by Roger de Newburgh in 1123. Tel: +44 (0)1926 403940

E-mail: [email protected]

www.stmaryswarwick.org.uk

Coventry Cathedral

Coventry has had three Cathedrals in the past 1000 years: the 12th century Priory Church of St Mary, the medieval Parish Church Cathedral of St Michael and the modern Coventry Cathedral, also named for St Michael. Coventry’s fortunes and story are closely associated to the story of its Cathedrals - a story of death and rebirth.Tel: +44 (0)24 7652 1200

www.coventrycathedral.org.uk

Places of Interest

Coventry Transport Museum

Coventry is the birthplace of the British cycle and motor industry. The Museum’s collection includes over 240 cars, commercial vehicles and buses, 94 motorcycles, 200 cycles, 25,000 models and around 1 million archive and ephemera items. This unique collection will enthral even the most avid enthusiast, but the displays tell other stories too: of invention, vision and enterprise; technology, skill and industry; passion, resilience and hope. Our journey spans 150 years and is told through the stories and products of the people that built an industry and helped build a city.Tel: 024 7623 4270

www.transport-museum.com

Hill Close Gardens

This delightful network of individual Victorian gardens, separated by high hedges, has recently been restored using Heritage Lottery funding. Delightful summerhouses, gnarled old fruit trees, and heritage fl owers and vegetables welcome the visitor to this tranquil spot.Tel: 01926 493339E-mail: [email protected]

www.hillclosegardens.com

Kenilworth Castle

Travel back in time at Kenilworth Castle and tread the fl oors where kings and queens once danced and dined at this beautiful castle ruin. We have something for the whole family to enjoy from exhibitions, a delightful castle tearoom and beautiful walks to our exciting events programme. The vast medieval fortress of Kenilworth Castle is one of the largest historic visitor attractions in the West Midlands and one of the most spectacular castle ruins in England.Tel: 0870 333 1181

www.english-heritage.org.uk/kenilworth

Lord Leycester Hospital and Master’s Garden

The historic group of buildings that now comprise the Hospital, is now dominated by the ancient Chantry Chapel of St James, built over the West Gate into Warwick by Thomas Beauchamp, 12th Earl of Warwick, in the latter half of the 14th Century.Tel: +44 (0)1926 491422E-mail: [email protected]

Website: www.lordleycester.com The Mill Garden

At the bottom of Mill Street is the Mill Garden, famed for the quality of its planting in an unbelievable setting. It was created over a period of sixty years by the late Arthur Measures, who made it a personal expression of his love of plants.Tel: 01926 492877 Saltisford Canal Trust

Colourful canal urban fringe park, run by local charity on the Saltisford Arm of the Grand Union Canal. Gardens, picnic sites, day hire canal boats with full disabled access, canal side shop and information centre, refreshments, day fi shing and overnight visitor moorings.Tel: +44 (0)1926 490006

www.saltisfordcanal.co.uk

St John’s Museum

A charming Jacobean mansion housing period reconstructions of a Victorian kitchen and classroom. Includes toys and dolls.Tel: +44 (0)1926 412132 or 412021E-mail: [email protected]

www.warwickshire.gov.uk/museum St Nicholas Park

Includes a crazy golf course, amusement rides, children’s play area, pony rides, outdoor paddling pool and boats for hire (summer only), tennis, football courts, recreation ground, indoor swimming pool and leisure centre, sports facilities, cafe, BMX track and Boules rink.Tel: 01926 495353

www.stnicholaspark.co.uk

The Queen’s Own Hussars Museum

The Cavalry Regiment of the West Midlands – the past to the present. Riding into Battle by Horse and Tank. One of the three Warwick Military MuseumsTel: 01926 492797

[email protected]

www.qohmuseum.org.uk

Warwick Castle

Britain’s Ultimate Castle! Where you can immerse yourself in a thousand years of jaw-dropping history - come rain or shine. Experience the excitement of Merlin: The Dragon Tower an exhilarating and interactive experience inspired by the hit BBC One family drama. New for Easter 2012, the Witches of Warwick arrive in the Castle Dungeon bringing morbid spells and the darkest witchcraft games that will create an atmosphere so malevolent and chilling, even seasoned scaremongers will be terrifi ed.Tel: +44 (0)870 442 2000E-mail: [email protected]

www.warwick-castle.com

Warwickshire Museum

The Warwickshire Museum contains displays of Archaeology, Geology and Natural History, The Great Fire of Warwick and Sheldon’s Tapestry Map.Tel: +44 (0)1926 412500 or 412501

www.warwickshire.gov.uk/museum

Warwick Racecourse

Warwick Racecourse is one of the leading fl at and steeple chasing courses and has a regular programme of 22 meetings throughout the year. The central grandstand incorporates the fi rst stand built in 1808. In 2000 it underwent a £3 million refurbishment.Tel: 01926 491553Fax: 01926 403223E-mail: [email protected]

www.warwickracecourse.co.uk/

Warwick Castle

Coventry Cathedral

Collegiate Church of St Mary

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Local Restaurants and Hotels

There are a number of restaurants at The University of Warwick. For alternative restaurants please review Trip Advisor www.tripadvisor.co.uk which lists restaurants within a 2-mile radius of the campus.

Hotel NameApproxDistance

StarRating

Pricesfrom £p/night

Web Address Telephone No.

Radcliff (Warwick Conferences)

0.1m 3 93.00www.warwickconferences.com/our-venues/accommodation

0247652 3222

Village Urban Resort 1.7m 3 135.00 www.village-hotels.co.uk/coventry 0871 222 4193

The Cottage Inn (Pub)

2.0m N/A 39.50 www.thecottageinn.co.uk 01926 853900

Loch Fyne Restaurant and Milsoms Hotel

2.3m 4 77.50 http://www.milsomshotel.co.uk/kenilworth.php 01926 515 450

Nailcote Hall Hotel and Leisure

2.4m 4 135.00 www.nailcotehall.co.uk/ 02476 466174

Ramada Hotel and Suites

2.4m 4 81.00 www.ramada.com/coventry 024 76238110

Holiday Inn Kenilworth

2.4m 4 80.00 www.holidayinn.com 0871 4234828

Woodside A Sundial Venue

2.5m 4 94.00 www.sundialgroup.com/woodside/ 08455 049550

Old Mill Hotel by Good Night Inns

2.6m 4 70.00 www.goodnightinns.co.uk/hotel-booking/old-mill/ 02476 302241

Castle Laurels Guest House

2.6m 4 45.00 http://www.castlelaurels.co.uk/ 01926 856 179

Days Hotel 2.7m 3 45.00 www.dayshotel-coventry.co.uk 024 7625 8585

Brooklands Grange Hotel

2.8m 3 56.00 www.booking.com/brooklands-grange-hotel 024 76601601

Highcroft Guest House

2.8m 3 30.00 www.highcroftguesthouse.com 0247622 8157

Best Western The Peacock Hotel

2.9m 3 67.50 www.peacockhotel.com 01926 851 156

Premier Inn Coventry South

3.2m 3 57.00 www.premierinn.com 0871 527 8270

Seetar Tandoori 2.5 4 N/A www.seetartandoori.co.uk (Trainees Dinner Venue) 01926 851585

* Star ratings and prices are based on Trip Advisor or Late Rooms and intended to act as a guide only

Social Events

Opening Reception and Industry Speed DatingWednesday , 2nd April - 18.45-21.00

Mead Gallery and Butterworth Hall

The Welcome Reception will take place along with the introduction of “Industry Speed Dating “

The purpose of this part of the evening is to allow maximal introduction of delegates to trade representatives, in 5 minute slots over 90 minutes. A bell will ring to ensure that everyone moves along to the next stand. Canapés and drinks will be available at every station.

Gala DinnerStoneleigh Abbey, Kenilworth, Warwickshire, CV8 2LF

Thursday, 3rd April – 19.00-23.30

Coaches depart Warwick Arts Centre 19.00-19.20 In Library Road (at the bottom of the Social Sciences courtyard)

Coaches return 23.15-23.30

The lakeside setting of the fairy-tale Stoneleigh Abbey was popular in the 19th century with wealthy Warwickshire families and off ers unrivalled links with the romantic fi ction of Jane Austen. The West Wing’s ornate State Rooms facing on to the parkland are very impressive. The Gala Dinner will be held in the old Riding School, now the Banqueting Hall.

The guest speaker will be the internationally acclaimed Professor Peter Welton, D. Litt, whose paintings will also be on display. At the end of the meal guests will be given a demonstration of Bollywood style dancing and we will all be encouraged to join in!

Stoneleigh Abbey

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International Faculty

Hanne Albert

Denmark

Has worked as a full-time researcher since 2000, fi rst as an Associate Professor at the Institute of Regional Health Services Research, University of Southern Denmark, Denmark. She is now in the process of moving to a research position at St Bartholomew’s Hospital, London. Her main interest is clinical research in Modic changes, lumbar disc herniation and pelvic girdle pain.

Eugene Carragee

USA

Is a Professor and Vice-Chairman in the Department of Orthopaedic Surgery in the Stanford University School of Medicine. He received his MD in orthopaedic surgery and internal medicine at Stanford and performed his fellowship in spine and paediatric surgery at the University of Hong Kong. He trained in the US Army Medical Corps and served as a public health offi cer, Battalion and Command Surgeon and a Forward Surgical Team Commander. Specialties include adult spinal reconstructive surgery, cervical and lumbar disc and fusion surgery, spinal tumors and infections and spinal deformities. Research interests include surgical and rehabilitative treatment for cervical lumbar intervertebral disk herniation; spine infections; degenerative spine and spinal deformities instrumentation and low back pain syndromes.

Wilco Jacobs

The Netherlands

Is a biomedical health scientist and epidemiologist at the Department of Neurosurgery of the Leiden University Medical Centre, The Netherlands. He supports the organisation and practice of research on spinal interventions and specialises in clinical research in spinal surgery and systematic literature reviews. He has extensive experience in Cochrane reviews, other reviews including observational designs and numerous support to reviewers in several fi elds. His PhD thesis was on the methodology of research and systematic reviews in spinal surgery. By means of meta-epidemiological studies the infl uence of design on the fi ndings of primary studies and reviews was investigated.

Joseph Perra

USA

Is Staff Surgeon at the Twin Cities Spine Centre, Minnesota. He attended the University of Minnesota Medical School from 1980-1984. His internship in surgery took place from 1984-1985 at the Southwestern Michigan Area Health Education Centre, Kalamazoo, Michigan. His residency in orthopaedic surgery was at the Michigan State University, Kalamazoo Centre for Medical Studies from 1985-1990. His spine fellowship was from 1990-1991 at the Minnesota Spine Centre. His specialties include cervical and lumber, scoliosis/deformities.

Wilco Peul

The Netherlands

Is trained as a neurosurgeon and epidemiologist. With regard to both expertises, he defended his PhD (cum laude) at Leiden University. The spinal studies he constructed resulted in numerous publications in spine journals and several high impact papers in NEJM, JAMA and BMJ. Besides spinal training activities within the EANS, he is active as representative of the latter society with the construction of spinal curriculum of the UEMS. Currently he works as a spinal neurosurgeon with particular interest in craniocervical reconstructive surgery. Since 2009 he has chaired the department of neurosurgery at the Leiden University Medical Centre & Medical Centre The Hague, The Netherlands.

Industry Faculty

Gianluca Iasci

K2M

Has served as K2M Executive VP of Global Sales since May 2013 and as Senior VP International from July 2011. Prior to joining K2M he served as Senior VP EMEA at AGA Medical. He has over 20 years’ experience in the medical device industry, spending 12 years with Johnson & Johnson in various European Sales and Marketing positions, based in Germany and Italy, four years at Guidant as Managing Director and four years at St Jude Medical in both national and international positions, based in Italy and Hong Kong. Mr Iasci holds a degree in Economics and he served as an offi cer in the Italian Army.

Max Reinhardt

DePuy Synthes

Worldwide President for DePuy Synthes Spine. Max began his career with DePuy Spine in 2002 as Director of Sales and Marketing in the UK. In 2006, he relocated to the US as Vice-President, US Sales for DePuy Spine and then in early 2011, assumed the position of Vice-President, Worldwide Marketing for DePuy Spine. Prior to joining Johnson & Johnson in 2002, Max held various sales and marketing roles with Olympus KeyMed and Steris. Max earned his Higher National Diploma at Sparsholt College of Agriculture in the UK and his Master of Science degree in marketing from the University of Hull, also in the UK.

Todd Harrington

Stryker

Began his career with Stryker Spine in 1997 when he was hired as one of the fi rst project engineers of the newly formed business unit. In 1999 he took on the role of Sales Representative responsible for Colorado before being promoted to the role of Spine Sales Manager for the Summit Surgical Branch. In 2004 he was promoted to Regional Sales Manager for the Pacifi c Region responsible for Southern California, Arizona, Las Vegas, Utah and Southern Idaho. He became the Director of Strategic Sales and Marketing for the Western US in 2006. He was promoted Director of Business Development for Stryker Spine in 2008 during which he was responsible for leading the division’s licensing and acquisition activities as a member of the Senior Leadership Team. In 2011 he was promoted Vice President, Strategic Development & Professional Aff airs. While continuing to lead Spine’s Business Development activities, he also assumed the lead of Spine’s customer experience initiatives including Medical Education, Industry and Society Relations, Professional Relations and Professional Aff airs. He is a graduate of Cornell University where he earned both a Master’s of Engineering and a Bachelor’s of Science Degree in Mechanical Engineering.

Tapio Videman

Canada

Is Professor Emeritus. He has an interest in etiognosis, diagnosis and prognosis of spinal disorders and disc degeneration and anti-antidoping. He has been lucky to have had A Langenskiöld, J D G Troup, H Farfan, O S Miettinen and M C Battié as mentors and colleagues. He has been recognised with a number of international research awards including: ISSLS Volvo Awards: 1990, 1991, 1994, 1995, 1998 and 2012 ISSLS Prize Kappa Delta Award 2008. “The Foundation of a New Paradigm of Disc Degeneration: The Twin Spine Study”

“Outstanding Paper Award” by The Spine Journal 2009

ISSLS Wiltse Lifetime Achievement Award 2011

Controlling doping tests at World Ski Championships and Winter Olympics.

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National Faculty

Sashin Ahuja

Consultant Spinal Surgeon, University Hospital of Wales & University Hospital Llandough, Cardiff

Nick Birch

Consultant Spinal Surgeon, Woodland Hospital, Kettering. Treasurer of the United Kingdom Spine Societies Board (UKSSB) which represents UK based specialist spine societies.

Rolfe Birch

Consultant Orthopaedic Surgeon

Lee Breakwell

Consultant Spinal Surgeon, Sheffi eld Children’s Hospital

Alan Breen

Professor of Musculoskeletal Healthcare, Institute of Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic (AECC)

Elaine Buchanan

Consultant Physiotherapist, Oxford University Hospitals. Board Member of United Kingdom Spine Societies Board (UKSSB). Secretary of Society for Back Pain Research

David Chapple

Consultant Spinal Surgeon, SalisburyDirector, South West Spinal Unit

Adrian Casey

Consultant Spinal Surgeon, Royal National Orthopaedic Hospital, Stanmore & The National Hospital for Neurology and Neurosurgery, Queen Square, London. Board Member of United Kingdom Spine Societies Board (UKSSB). President of British Association of Spine Surgeons

Ashley Cole

Consultant Orthopaedic Spinal Surgeon, Sheffi eld Children’s & Northern General Hospitals

Evan Davies

Lead Paediatric Spinal Surgeon & Adult Orthopaedic Spine Surgeon, Southampton University & Spire Hospitals, Southampton

Michael Devlin

Head of Professional Standards and Liaison, Medical Defence Union

Jeremy Fairbank

Professor of Spinal Surgery, Nuffi eld Orthopaedic Centre, Oxford University Hospitals. Past-President of British Scoliosis Society. President of the International Society for the Study of the Lumbar Spine. Chair of the United Kingdom Spine Societies Board (UKSSB) which represents UK based specialist spine societies

Mike Gibson

Consultant Spinal Surgeon, Royal Victoria Infi rmary, Newcastle-upon-Tyne

Chris Godeseth

Medical Risk Manager, Medical Protection Society

Charles GreenoughQualifi ed from Queen’s College, Cambridge and University College Hospital, London. He trained as an orthopaedic surgeon at the Royal Free Hospital, London and the Royal National Orthopaedic Hospital, Stanmore. Specialist spinal training was also undertaken at the Royal Adelaide Hospital, South Australia. He is now Consultant Spinal Surgeon at the James Cook University Hospital, Middlesbrough. He is also Clinical Director of the Golden Jubilee Regional Spinal Cord Injuries Centre and Professor of Spinal Studies at the University of Durham. His vision as National Clinical Director for Spinal Disorders is to promote a seamless care pathway for patients with low back pain or sciatica across NHS to reduce long term disability and multiple ineff ective therapies

Louise Hailey

Clinical Specialist Physiotherapist, Oxford Spinal Unit

Ian Harding

Consultant Orthopaedic Spinal Surgeon, Frenchay Hospital, Bristol

Pete Millner

Consultant in Orthopaedic and Spinal Surgery, Leeds General Infi rmary, Honorary Secretary of British Scoliosis Society (BSS), Board Member of United Kingdom Spine Societies Board (UKSSB), Board Member of British Scoliosis Research Foundation

Sean Molloy

Consultant Orthopaedic Spinal Deformity Surgeon, Royal National Orthopaedic Hospital, Stanmore

Nigel Montgomery

(Beechcroft’s Solicitor for the NHS Litigation Authority)

Ian Nelson

Consultant Orthopaedic Surgeon, Frenchay Hospital Bristol. Board Member of United Kingdom Spine Societies Board (UKSSB) and President of British Scoliosis Society.

Ms Sara Owen

Former Vice-Chair Oxford A Research Ethics Committee

Am Rai

Consultant Spinal Surgeon, Norfolk & Norwich University Hospital, Foundation Programme Director and Board Member of United Kingdom Spine Societies Board (UKSSB). Secretary British Association Spinal Surgeons

John O’Dowd

Consultant Spinal Surgeon, London & Hampshire and Board Member of United Kingdom Spine Societies Board (UKSSB). President of Society for Back Pain Research

Phil Sell

Orthopaedic Spinal Surgeon, University Hospitals of Leicester. Past-President and Past-Secretary of the British Association of Spine Surgeons. Has had active roles on the Executive of the Society for Back Pain Research and the British Scoliosis Society. He is an active member of the Spine Society of Europe and has had roles within the Executive, the Education Committee and is the current Chair of the Scientifi c Programme Committee

Nilam Shergill

Consultant Spinal Surgeon, University Hospital Coventry & Warwickshire.Honorary Associate Clinical Professor

Robert Sneath

Consultant Spinal Surgeon, University Hospital Coventry & Warwickshire. Honorary Associate Clinical Professor

Alistair Stirling

Consultant Spinal Surgeon, The Royal Orthopaedic Hospital, Birmingham. Board Member of United Kingdom Spine Societies Board (UKSSB)

Nick Todd

Consultant Spinal Neurosurgeon

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Programme Outline and Key

Tuesday, 1st April 2014

08.30-09.00 Registration – Trainees only Conference Reception – Ground Floor Students Union

09.00-19.00 Trainees Cadaveric Workshop West Midlands Surgical Training Centre, University Hospital, Coventry

11.30-18.30 Registration Mezzanine fl oor – Warwick Arts Centre

12.00-20.00 Exhibition set up Butterworth Hall and Mead Gallery

13.00-16.00 BASS Executive School of Social Sciences

16.00-18.30 UKSSB Meeting School of Social Sciences

18.30-23.00 Faculty Dinner Dorridge

18.30-23.00 Trainees Dinner Kenilworth

Wednesday, 2nd April 2014

08.00-18.00 Registration Mezzanine fl oor - Warwick Arts Centre

07.30-08.30 Breakfast Meetings School of Social Sciences

Main Theatre Woods-Scawen Theatre

08.30-08.45 Welcome

08.45-10.00 Papers Lumbar Degenerative BASS Session 1

10.00-10.30 Keynote Lecture 1

10.30-11.00 Coff ee & Exhibition Mead Gallery & Butterworth Hall

11.00-12.00 Papers Tumour 1 BASS Session 2

12.00-12.30 Keynote Lecture 2

12.30-13.45 Workshops School of Social Sciences & Library 1 & 2

Lunch Mead Gallery & Butterworth Hall

13.45-14.45 Symposia Symposia

14.45-15.15 Coff ee & Exhibition Mead Gallery & Butterworth Hall

15.15-16.15 Papers Tumour 2 BASS Session 3

16.15-17.00 Debate

17.00-17.10 Introduction to Industry Speed Dating

17.10-18.30 Workshops School of Social Sciences

18.45-21.00 Welcome Reception Mead Gallery & Butterworth Hall

Audit Debate Keynote Lectures Special Posters Workshops

BASS eSpine SBPR Symposia

BSS Lumbar Degenerative Social Tumour

Programme Outline and Key

Thursday, 3rd April 2014

08.00-18.00 Registration Mezzanine fl oor - Warwick Arts Centre

07.30-08.30 Breakfast Meetings School of Social Sciences

08.30-09.40 Papers BSS Session 1 SBPR Session 1

09.40-10.10 Keynote Lecture 3

10.10-10.30 Audit British Spine Registry

10.30-11.00 Coff ee & Exhibition Mead Gallery & Butterworth Hall

11.00-11.30 Keynote Lecture 4

11.30-12.40 Papers SBPR Session 2 BSS Session 2

12.40-13.55 Workshops School of Social Sciences & Library 1 & 2

Lunch Mead Gallery & Butterworth Hall

13.55-14.40 Keynote Lecture 5

14.40-15.40 Symposia Symposia

15.40-16.00 Coff ee & Exhibition Mead Gallery & Butterworth Hall

16.00-16.05 eSpine launch

16.05-17.00 AGM UKSSB

17.00-18.30 AGM BASS

19.00-23.00 Gala Dinner Stoneleigh Abbey

Friday, 4th April 2014

08.00-16.00 Registration Mezzanine fl oor - Warwick Arts Centre

07.45-08.45 Breakfast Meetings School of Social Sciences

08.45-09.15 Keynote Lecture 6

09.15-10.30 Special Posters Surgical Non-Surgical

10.30-11.00 Keynote Lecture 7

11.00-11.30 Coff ee & Exhibition Mead Gallery & Butterworth Hall

11.30-12.15 Debate

12.15-12.45 Prize Giving

Farewell

12.45-13.30BritSpine committee meeting

School of Social Sciences

13.30-14.00 Registration Patients’ Meeting Mezzanine fl oor - Warwick Arts Centre

14.00-17.30 Patients’ meeting Main Theatre

Audit Debate Keynote Lectures Special Posters Workshops

BASS eSpine SBPR Symposia

BSS Lumbar Degenerative Social Tumour

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24 25BRITSPINE 2014BRITSPINE 2014

Programme

Tuesday, 1st April 2014

08.30-09.00REGISTRATIONTrainees Cadaveric Workshop

Students Union (opposite Costa Coff ee)

08.00-09.00 09.00 Sharp! Bus to take trainees to the West Midlands Surgical Training Centre, University Hospital, Coventry

Stations hosted by: Depuy Synthes Spine

Stryker Spine

K2M Inc

Globus Medical

NuVasive Inc

Each 65 to 70 minute cadaveric session will be preceeded by a fi ve minute slide presentation by the faculty.

Teaching Faculty: Mr Stuart Blagg, Mr Alwyn Jones

Mr Rex Michael

Mr Ramesh Nadarajah

Mr Colin Natali, Mr Am Rai

Mr Ed Seel, Mr Masood Shafafy

Mr Nilam Shergill

Mr Robert Sneath

Exercise 1 Posterior Cervical Approaches and Instrumentation

Exercise 2 Posterior Thoracic Approaches and Instrumentation

Exercise 3 Posterior Lumbar Approaches and Instrumentation

LUNCH

Exercise 4 Anterior Cervical Approaches and Instrumentation

Exercise 5 Anterior/Lateral Thoracic Approaches and Instrumentation

Exercise 6 Anterior/Lateral Lumbar Approaches and Instrumentation

19.00 Bus to take trainees to the West Midlands Surgical Training Centre, University Hospital, Coventry

19.30 Collect left luggage and take to rooms

20.00 Bus to take trainees to dinner

23.00 Bus to take trainees back to the Warwick Arts Centre

11.30-18.30 REGISTRATIONMain BritSpine Conference

Mezzanine fl oor - Warwick Arts Centre

12.00-20.00 EXHIBITION SET UP Butterworth Hall and Mead Gallery

13.00-16.00 BASS EXECUTIVE MEETING School of Social Sciences

16.30-18.30 UKSSB MEETING School of Social Sciences

18.30-23.00 FACULTY DINNER Dorridge

18.30-23.00 TRAINEES DINNER Kenilworth

Programme

Wednesday, 2nd April 2014

08.00-18.00 REGISTRATION Mezzanine fl oor - Warwick Arts Centre

07.30-08.30 BREAKFAST MEETINGS School of Social Sciences

MAIN THEATRE WOODS-SCAWEN THEATRE

08.30-08.45 WELCOME Nilam Shergill

08.45-10.00 PAPERS LUMBAR DEGENERATIVE BASS SESSION 1

Chairs Adrian Casey, Tapio Videman Ian Nelson, Joseph Perra

08.50-09.00 The outcome of decompression without fusion for lumbar spinal stenosis in the presence of degenerative spondylolisthesis

S Ahmad, A Bhalla, S Turner, B Balain, D Jaff ray

Diagnostic yield of whole spine sagittal T2 as an additional MRI sequence in “cauda equina syndrome”

Vinay Jasani, Abdul Khader Hamad, Sandeep Konduru, Nik Tzerakis, El Nasri Ahmed, Mark Brown

09.00-09.10 A 7 Year Follow-Up of Dynesys and Interbody Fusion for Discogenic Lower Back Pain: Short Term Hope or Long Term Cure?

Budd H, Sharp D, Powell J, Cumming D

How Anal are we about “Anal Tone” in patients with suspected Cauda Equina Syndrome

Ravi Badge, H Divecha, J Stephenson, I Siddique, S Mohammad, R Verma

09.10-09.20 360-degree versus Posterolateral Instrumented Fusion for Spondylolytic Spondylolisthesis: Does added cost translate to additional clinical value?Budd H, Inaparthy P, Sharp D, Powell J, Chan D, Cumming D

Epidemiology of spinal trauma presenting to a regional neurosurgical centre

Difei Wang, Stephen Scullion, Peter Hutchinson, Alexis Joannides, Douglas Hay

09.20-09.30 Recovery of severe motor defi cit secondary to lumbar disc prolapse: Is surgical intervention necessary? A systematic review

Balaji V, Chin K, Tucker S, Wilson L, Casey A

Traumatic central cord syndrome: Neurological and functional outcome, an experience from a regional Spinal Injuries Centre

Srinivasa Chakravarty Budithi, Naveen Kumar

09.30-09.40 Spinal fusion is associated with increased adjacent segment disc degeneration but without infl uence on clinical outcome. Results of a combined long-term follow-up from 4 RCTs

Mannion AF, Leivseth G, Brox JI, Fritzell P, Hägg O, Fairbank JC

Do surgeon credentials aff ect the rate of incidental durotomy during spine surgery: evidence from the international Spine Tango Registry

Andreas Demetriades, Nicholas Murray, Colin Nnadi

09.40-09.50 Discogenic Lower Back Pain: A Long-Term UK Clinical Follow-up of the DYNESYS implant

Budd H, Sharp D, Powell J, Cumming D

A 10 year review of unstable thoracolumbar spinal fractures from Northern Ireland: The associated injuries

Stacey Thomson, Harriet Julian, Eugene Verzin, Greg McLorinan, Niall Eames

09.50-10.00 Schizas grading for spinal stenosis reproducibility

Catherine Gibson, Harshad Dabke

Expecting Too Much? A Comparison Of Estimated And Actual Surgical Times

John Kiely, Himanshu Sharma

10.00-10.30 KEYNOTE LECTURE 1

Complex cervicothoracic deformitiesJoseph Perra

10.30-11.00 COFFEE & EXHIBITIONButterworth Hall and Mead Gallery

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Programme

MAIN THEATRE WOODS-SCAWEN THEATRE

11.00-12.00 PAPERS TUMOUR 1 BASS SESSION 2

Chairs Am Rai, Eugene Carragee Sashin Ahuja, Robert Sneath

11.00-11.10 The Use of Salvaged Blood in Metastatic Spine Tumour Surgery: Dispelling an Old Myth

Naresh Kumar, Yongsheng Chen, Aye Sandar Zaw, Qasim Ahmed, Victor Lee, Hee-Kit Wong

Single injection epidural analgesia with local anaesthetic for pain relief following spinal surgery: a prospective randomised study

Douglas Wardlaw, Amol Rege, Paul Martin, David Knight

11.10-11.20 The fi nancial cost for the surgical treatment of metastatic spinal cord compression

Ben Fischer, Hiren Divecha, Saeed Mohammad, Rajat Verma, Irfan Siddique

Endoscopic Epidural Adhesiolysis in FBSS patients with MRI documented epidural fi brosis

Stefano Palmisani, Thomas Smith, Adnan Al-Kaisy

11.20-11.30 The Incidence of Venous Thromboembolic Disease Following 827 Elective Spinal Procedures at a District General Hospital

Peter Ralte, Seif Sawalha, Chris Prior, Veenesh Selvaratnam, Yuen Chan, Ian Shackleford, Shashank Chitgopkar

The value of routine postoperative radiographs after elective lumbar spinal fusion surgery

Sarah Carter, Syed Ali, Manoj Khatri

11.30-11.40 The role of timing of surgery and comorbidities in metastatic spinal cord compression (MSCC). Is this a useful predictor of neurological recovery? The Oswestry experience

Bhalla A, Ahmad S, Balain B, Trivedi J, Jaff ray D

Avoiding Wrong Site Surgery in Spine: Think Head

G O Alo, Sanjay Purushothamdas, M Arif

11.40-11.50 Computer tomography assessed muscle mass as an indicator of longevity in patients with spinal metastasis

Harinder Gakhar, Bommireddy R, Calthorpe R, Klezl Z, Williams J

The Role of Bone Morphogenetic Protein in Revision Lumbar Spine Surgery for Pseudarthrosis: Can We Finally Believe the Hype? A Systematic Review

Balaji V, Kaila R, Fonseka S, Patczai M, Divani K, Tucker S, Wilson L

11.50-12.00 Outcome of surgical management of spinal metastases in a district general hospital

E Bagouri, R El-Hassan, AM Hill, L Jagonase, S England, AT Cross, GS Roysam, P Lakshmanan

Role for day case surgery in patients undergoing lumbar micro-discectomies and decompressions spinal procedures

Kristy Kehoe, Ashish Pattni , Anne Moore, Himanshu Sharma

12.00-12.30 KEYNOTE LECTURE 2

Spinal Implant Companies & Spinal Surgeons: The Past, Present & FutureMax Reinhardt

12.30-13.45 WORKSHOPS School of Social Sciences & Library 1 & 2

LUNCH Butterworth Hall and Mead Gallery

13.45-14.45 SYMPOSIA Industry Question Time Chronic spinal pain: managing rather than curing

Chairs Nick Birch Hanne Albert

Panel Max Reinhardt, Eugene Carragee, Wilco Peul, Ian

Nelson, Gianluca Iasci, Todd HarringtonCharles Greenough Charles Pither Wilco Jacobs

14.45-15.15 COFFEE & EXHIBITIONButterworth Hall and Mead Gallery

Programme

MAIN THEATRE WOODS-SCAWEN THEATRE

15.15-16.15 PAPERS TUMOUR 2 BASS SESSION 3

Chairs Pete Millner, Wilco Peul John O’Dowd, Ashley Cole

15.15-15.25 The Use of Intra-operative Salvaged Blood in

Metastatic Spine Tumour Surgery: A Systematic

Review of the Literature

Naresh Kumar, Yongsheng Chen, Aye Sandar Zaw,

Qasim Ahmed, Richie Soong, Hee-Kit Wong

Spinal Surgery Procedure Specifi c Consent: An

Overdue Evolution of the Consent Process for

Specialised Surgery

Budd H, Wood R, Sharp D, Powell J, Bhagat S

15.25-15.35 The Role of Preoperative Vascular Embolization

in Surgery for Spinal Metastases

Naresh Kumar, Barry Tan, Priyanka Gahlot, Aye Sandar

Zaw

Retrospective review of mechanical

thromboprophylaxis in patients undergoing

spinal surgery and National Survey of current

venous thromboembolism practice in England

Lamb JN, Boddice T, Loughenbury PR, Rudol G and

Khan AL

15.35-15.45 Validation of the Oswestry Spinal Risk Index

Whitehouse S, Stephenson J, Gregory J, Sinclair V,

Tambe A, Verma R

Is Chemical prophylaxis for Venous Thrombo-

Embolism needed post- operatively in elective

Spinal Surgery? A comparison of practice study

and a tertiary centre review of 2472 consecutive

procedures over 5 years

H Fawi, A Cunningham, K Saba, S Masud, M Lewis, P

Davies, J Howes, S James, A Jones, I Chopra, S Ahuja

15.45-15.55 Survival in surgically managed metastatic spinal

cord compression

Hiren Divecha, Benjamin Fischer, Dmitri van Popta,

Ravindra Badge, Irfan Siddique, Saeed Mohammad,

Rajat Verma

Effi cacy,safety and cost-eff ectiveness of a same

day discharge pathway in spinal surgery

Adarsh Nadig, Saeed Mohammad, Rajat Verma, Irfan

Siddique

15.55-16.05 30, 60, and 90 day mortality in metastatic spinal

cord compression (mscc) patients. are we making

the right decision to avoid surgical morbidity?

the oswestry experience

Bhalla A, Ahmad S, Fawdington R, Balain B, Trivedi J,

Jaff ray D

Surgical Site Infection in Spinal operations

A tertiary centre review of 4557 consecutive

procedures over 5 years

H Fawi, M Ahmed, M Lewis, J Magol, P Davies, J

Howes, S James, I Chopra, A Jones and S Ahuja

16.05-16.15 Posterior stabilisation for metastatic spinal

lesions: Radiographical follow-up of 100 patients

Harriet Julian, Stacey Thomson, Eugene Verzin, Greg

McLorinan, Nagy Darwish, Niall Eames

A Northern Ireland retrospective review of

lumbar fusion: effi cacy of intrathecal vs epidural

administered anaesthesia on post-operative

pain

Rakesh Dhokia, Morgan Jones, Eugene Verzin,

Greg Mclorinan, Eddie Cooke, Paul Nolan, Alistair

Hamilton, Niall Eames

16.15-17.00 DEBATE Degenerative scoliosis requires full deformity correction

For Sean Molloy, Ian Harding

Against Mike Gibson, Evan Davies

Chair Jeremy Fairbank

17.00-17.10 ANNOUNCEMENT

Introduction to Industry Speed Dating at the Welcome Reception

17.10-18.30 WORKSHOPS School of Social Sciences & Library 1 & 2

18.45-21.00 WELCOME RECEPTION

Butterworth Hall and Mead Gallery (Industry Speed Dating for fi rst 90 minutes)

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Programme

Thursday, 3rd April 2014

08.00-17.30 REGISTRATION Mezzanine fl oor - Warwick Arts Centre

07.30-08.30 BREAKFAST MEETINGS School of Social Sciences

MAIN THEATRE WOODS-SCAWEN THEATRE

08.30-09.40 PAPERS BSS SESSION 1 SBPR SESSION 1

Chairs Sean Molloy, Joseph Perra John O’Dowd, Hanne Albert

08.30-08.40 The eff ect of metal density on thoracic and lumbar curve coronal correction in thoracic adolescent idiopathic scoliosis

Rushton PRP, Basu S, Cole AC, Grevitt MP

Prevalence of Vitamin D defi ciency in patients presenting with low back pain in an outpatient setting

Kwang Chear Lee, Asif Khan, Stephen Longworth, Philip Sell

08.40-08.50 Does the rib hump return after costoplasty: A surface topography and radiographic review

Bowey AJ, Purushothaman B, Lees D, Bowers E, Gibson MJ

Identifi cation of obstacles to recovery in secondary care

Kwang Chear Lee, Shakil Patel, Philip Sell

08.50-09.00 Spinal deformities in muccopolysaccharidosis type 1 (Hurler’s) patients in the era of Bone Marrow Transplant

Tan J, Lui DF, Savage T, Burke N, Kennedy J, Kelly PM, Kiely P, Noel J

A potential minimally invasive nucleus pulposus replacement based on peptide/glycosaminoglycan hydrogels

Danielle E Miles, Sami Tarsuslugil, Elizabeth Mitchell, Nik Kapur, Ruth K Wilcox and Amalia Aggeli

09.00-09.10 Validation of the Perdriolle technique for measurement of apical vertebral rotation using digitally stored and enhanced radiographs

Grannum S, Landham P, Mckay, G, Patel MS, Hutchinson J, Hutchinson J, Nelson I

Morphometric analysis of facet joint arthropathy using high resolution SPECT/CT – a prospective clinical study

Vittorio M Russo, Ranju T Dhawan, Adrian TH Casey

09.10-09.20 Bone Rate With rhBMP-2 Versus Autologous Iliac Bone in PEEK Cages for Anterior Lumbar Interbody Fusion

Charles-Henri Flouzat Lachaniette, Amir Ghazanfari, Charlie Bouthors, Alexandre Poignard, Jérôme Allain

Self-organising biomimetic collagen/nano-HA/GaG scaff old for spinal fusion

Aman Sharma, Hua Ye, Jeremy Fairbank, Jan Czernuszka, Christopher Lavy

09.20-09.30 Improving the quality of lateral whole-spine radiographs used in spinal deformity surgery

Simon Craxford, Michael Gale, Oliver Stokes, Masood Shafafy

Does spinal manipulation change cervical inter-vertebral motion?

Jonathan Branney and Alan Breen

09.30-09.40 Incidence of neural axis anomalies on magnetic resonance imaging in early onset and adolescent idiopathic scoliosis patients

Amit Zaveri, Kiran Divani, Kia Rezajooi, Matthew Shaw, Alexander Gibson

Levels of Evidence of Spinal Research Published in the Highest Impact Medical Journals

Bakur A Jamjoom, Aimun A Jamjoom, Abdulhakim B Jamjoom

09.40-10.10 KEYNOTE LECTURE 3

Spondylolisthesis and Spinal Stenosis, a review of surgical interventionsWilco Jacobs

10.10-10.30 AUDIT British Spine RegistryLee Breakwell

10.30-11.00 COFFEE & EXHIBITIONButterworth Hall and Mead Gallery

Programme

MAIN THEATRE WOODS-SCAWEN THEATRE

11.00-11.30 KEYNOTE LECTURE 4

When disc height decreases - the vertebrae increase

Tapio Videman

11.30-12.40 PAPERS SBPR SESSION 2 BSS SESSION 2

Chairs Alan Breen, Louise Hailey Ian Harding, Mike Gibson

11.30-11.40 A comparison of (1) mri muscle fat content in psoas and erector spinae muscles and (2) patient reported outcome measures in patients with lumbar degenerative disc disease, L4/5 degenerative spondylolisthesis and L5/S1 lytic spondylolisthesis

Andrew Cunningham, Kiroless Saba, Michael McCarthy

Complications in Spinal Deformity Surgery in the United Kingdom. Five year results of the annual British Scoliosis Society National Audit of Morbidity & Mortality

Hiren M Divecha, Irfan Siddique, Lee M Breakwell, Peter A Millner

11.40-11.50 Assessment of Signs and Symptoms in the Diagnosis of Cauda Equina Syndrome – a Prospective single unit study

J Tomlinson, O Evans, R Michael, L Breakwell, N Chiverton, A Cole

A new medical device in the treatment of Early Onset Scoliosis (EOS): An audit of the reimbursement process

Babur Mahmood, Arvindera Ghag, Colin Nnadi

11.50-12.00 Spinal Injection Therapy Performed By Physiotherapists- A 2 Year Evaluation of 145 Trans Foraminal Epidural Steroid Injections

Patrick Hourigan. Helen Challinor, Andrew Clarke

Reducing the Pelvic Incidence through a S2 Pedicle Subtraction Osteotomy with Sacral-Pelvic Disarticulation and Anterior Pelvic Rotation

A Khurana, NA Quraishi

12.00-12.10 The eff ect of a functional restoration programme on disability, physical function and pain

Gareth J Venn, Graeme Paul-Taylor, Valerie Sparkes and Jennifer Moses

Multi- level Anterior Cervical Discectomy and Fusion: Clinical and Radiological outcomes

A Khurana, C Martini, BM Boszczyk, MM Tsegaye

12.10-12.20 A systematic review of interventions for preventing and treating low-back and / or pelvic pain during pregnancy

Sarah Dianne Liddle, Victoria Pennick

The Management of Thoracolumbar Deformity in the Mucopolysaccharidoses

Stephen AC Morris, Elizabeth Ashby, Ramesh Nadarajah, Tom Ember, Deborah Eastwood, Stewart Tucker

12.20-12.30 What happens to patients with symptoms of cauda equina syndrome, but a negative MRI scan?

Simon Craxford, Ashish Khurana, Julie Turner, Magnum Tsegaye

Incidence of False Positive Spinal Cord Monitoring Alerts in Surgery for Early Onset Scoliosis

OM Stokes, E Bayley, R Burton, DA Rothenfl uh and H Mehdian

12.30-12.40 A spinal ‘Enhanced Recovery and Education Programme’ for elective lumbar discectomy, decompression and fusion: The eff ect on patient length of stay

Matthew Brown, Sarah Parr, Theresa Maunganidze, Peter Dyson, James Langdon

A multicentre case series of muscle necrosis of the leg following spinal surgery with MEP monitoring - A cause for concern?

Kiran Divani, Andrew O Brien, Sean Molloy, Jayesh Trivedi, Alexander Gibson

12.40-12.50 Session may run over by 10 minutes... Flat backs in adolescent idiopathic scoliosis: is anterior surgery being overlooked?Bowey AJ, Purushothaman B, Lees D, Gibson MJ

12.40-13.55 WORKSHOPS School of Social Sciences & Library 1 & 2

LUNCH Butterworth Hall and Mead Gallery

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Programme

MAIN THEATRE WOODS-SCAWEN THEATRE

13.55-14.40 KEYNOTE LECTURE 5

The Infuse Aff air: How BMP-2 Came To AmericaEugene Carragee

14.40-15.40 SYMPOSIA Negligence and Indemnity New era of healthcare in the UK

Chair Nilam Shergill John O’Dowd

Panel Rolfe Birch, Nick Todd, Michael Devlin (MDU)Chris Godeseth (MPS), Nigel Montgomery (NHS Litigation Authority Solicitor)

Charles Greenough, Jeremy Fairbank, Ashley Cole

15.40-16.00 COFFEE & EXHIBITIONButterworth Hall and Mead Gallery

16.00-16.05 eSPINE eSpine LaunchSashin Ahuja

16.05-17.00 AGM UKSSB

17.00-18.30 AGM BASS

19.00-23.00 GALA DINNER Stoneleigh Abbey

19.00-19.20 Coaches leave WAC

23.10-23.30 Coaches return to WAC

Programme

Friday 4th April 2014

08.00-10.00 REGISTRATION Mezzanine fl oor - Warwick Arts Centre

07.45-08.45 BREAKFAST MEETINGS School of Social Sciences

MAIN THEATRE WOODS-SCAWEN THEATRE

08.45-09.15 KEYNOTE LECTURE 6

Is Surgery for Adult Spinal Deformity Cost-Eff ective?

Wilco Peul

SPECIAL POSTERS SURGICAL NON-SURGICAL

Chairs Charles Greenough, Nilam Shergill Elaine Buchanan, Wilco Jacobs

09.15-09.20 46. A Multi-Centre Retrospective Cohort Study of Spinal Osteoid Osteomas: Surgical treatment and local recurrence results

N A Quraishi, S Boriani, P Varga, A Luzzati, Z L

Gokaslan, M G Fehlings, C Fisher, M Dekutoski, L Rhines,

J Reynolds, C Bettegowda, N Kawahara, R Williams

31. Spinal Injection Therapy Performed By Physiotherapists- A 3 Year Evaluation of a New Service

Patrick Hourigan, Helen Challinor, Andrew Clarke

09.20-09.25 47. Survival of patients with Spinal Metastases from Nasopharyngeal Carcinoma Comparison of actual and predicted survival times

Naresh Kumar, Jonathan Tan, Aye Sandar Zaw, Joel Louis Lim, Khin Lay Wai

32. Spinal injections for neck and lower back pain in the radiology department: An Out-patient model

Maire-Clare Killen, L Jagonase, M Chandran, V Pancho, P Lakshmanan

09.25-09.30 48. Does surgical intervention within 48 hours in Cauda Equina Syndrome improve bladder outcome?

Nisaharan Srikandarajah, Simon Clark, Martin Wilby

33. Impact of Elite Sports Participation on Active Cervical Spine Range of Motion in Men

Bianca B Zietsman*, Ceri Ann Jones, Andrew Heusch, Peter W McCarthy

09.30-09.35 49. Short term follow up the UNIPLATE device for use in anterior cervical discectomy and fusion

Nick Rouholamin, Amit Patel, Ben Johnson, Vinay Jasani

34. Comparison of neurological improvements in Acute Traumatic Central Cord Syndrome following Surgical and Non-Surgical Interventions

Naresh Kumar

09.35-09.40 50. Long-term outcome following anterior cervical discectomy

LR Sabir, SM Scullion, AJ Joannides, RJC Laing

35. Will I be taller? - Height gain following scoliosis surgery

Z Alshameeri, N Din, S Charlton, D Conlan, J Crawford

09.40-09.45 51. C2/3 Anterior Cervical Discectomy and Fusion – A Case Series

Bethanabatla R, Jensen CD, Derham C, Timothy J, Thomson S, Towns G, Pal D

36. Therapeutic ive nerve root blocks for symptomatic lumbar disc herniation: one year follow-up and cost analysis

Ryan Wood, Henry Budd, David Cumming

09.45-09.50 52. Incidence of False Positive Spinal Cord Monitoring Alerts in Surgery for Late Onset Scoliosis

OM Stokes, E Bayley, R Burton, DA Rothenfl uh, H Mehdian

37. Syringomyelia secondary to dorsal arachnoid webs

Parag Sayal, Wisam Selbi, Ahilan Kailaya-Vasan, Arif Zafar, Thomas Carroll

09.50-09.55 53. Post-operative outcome following lumbar discectomy: The value of pre-operative radicular pain proportionHiren Divecha, Ben Fischer, Rajat Verma, Saeed Mohammad, Irfan Siddique

38. The impact of a One-Stop pre-assessment clinic in scoliosis surgery

Z Alshameeri, N Din, S Charlton, D Conlan, J Crawford

09.55-10.00 54. Analysis of Bone Morphogenetic Protein-2 (rhBMP-2) in Revision Lumbar Spine Fusion for Pseudarthrosis: A Minimum One-Year Follow Up Study

Rajiv Kaila, Venkatash Balaji, Lester Wilson

39. The relationship between pelvic incidence and spinopelvic sagittal parameters in adolescent idiopathic scoliosis- a prospective cohort meta analysis

Brett Rocos, John Hutchinson

screw system with sterile single-use instrumentation

Come and see a demonstration at Stand No 10, Butterworth Hall

t. 01536 267515f. 01536 205313e. [email protected]

Perth HouseCorby Gate Business ParkCorby, Northamptonshire

NN17 5JG

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SPECIAL POSTERS SURGICAL NON-SURGICAL

10.00-10.05 55. Modifi ed Hirabayashi Procedure (Open Door Laminoplasty) for the treatment of myelopathy secondary to ossifi cation of posterior longitudinal ligament – Sheffi eld experience

Daniel Brown, Ankur Saxena, William Ripley, Dev Bhattacharyya

40. A Retrospective Standard Based Audit to Evaluate Time to Assessment and Subsequent Management of Patients Diagnosed with Cauda Equina Syndrome (CES)

Joanne Roberts Denise Prescott Marcus deMatas

10.05-10.10 56. Cervical kinematics after total disc replacement (TDR): fl exion-extension and lateral bending motion patterns

Christian Mazel

41. Missed diagnosis of Spondyloarthropathy

Rohit Dhawan, V Pullicino, JM Trivedi

10.10-10.15 57. Can the Weinstein-Boriani-Biagini (WBB) radiological classifi cation system be used to guide us in the management and decision making of metastatic cord compression (MSCC) and potential neurological recovery?

Bhalla A, Ahmad S, Fawdington R, Gindar l, Balain B, Trivedi J, Jaff ray D

42. The infl uence of lumbar spine subtype on lumbar intervertebral disc degeneration in young and middle-aged adults

PAG Torrie, G McKay, R Bryne, SJ Morris, IJ Harding

10.15-10.20 58. Defi nitive Correction Following Growing Rod Treatment for Early Onset Scoliosis

Baxter G (Medical Student), Yasso S (Medical Student), Towriss C (Medical Student). James S (Consultant), Jones A (Consultant), Howes J (Consultant), Davies P (Consultant), Ahuja S (Consultant)

43. ‘Call the Spinal Surgeons’ – an increasing trend in emergency referrals

Timothy Hammett

10.20-10.25 59. Outcome following interbody fusion v/s posterolateral fusion for spondylolisthesis. is there a diff erence?

Harinder Gakhar, Seyed Almaleki, Ganesh Prasad, Hatem Salem, Rajendranath Bommireddy

44. Physiological compensatory mechanisms in the proximal and distal axial skeleton in adolescent idiopathic scoliosis

John Hutchinson, Brett Rocos

10.25-10.30 60. Changing prophylactic antibiotics for posterior spinal surgery: Are we putting our patients at risk?

Simon Craxford, Michael Gale, Masood Shafafy

45. Migrating intrathecal high velocity projectile

Yuen Chan, Rafi d Al-Mahfoudh, Robin Pillay

10.30-11.00 KEYNOTE LECTURE 7

Antibiotic treatment in patients with chronic low back pain and Modic Type changes: a double-blind RCT of effi cacyHanne Albert

11.00-11.05 Address “Getting It Right First Time” (GIRFT)Colin Howie (BOA President-Elect)

11.05-11.30 COFFEE & EXHIBITIONButterworth Hall and Mead Gallery

11.30-12.15 DEBATE Should antibiotics be given for back pain?

For Hanne Albert, Alistair Stirling

Against Wilco Peul, Jeremy Fairbank

Chair Phil Sell

12.15-12.45 PRIZE GIVING Nilam Shergill & Faculty Exhibitors dismantle stands

FAREWELL Nilam Shergill

Packed lunches available to take away

12.45-13.30 BritSpine Organising Committee Meeting

School of Social Sciences

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Programme

Friday 4th April 2014 (sponsored by the United Kingdom Spine Societies Board)

14.00-17.30 Chair Mr David Chapple Consultant Spinal Surgeon, Salisbury

Ms Sara Owen Former Vice-Chair Oxford A Research Ethics Committee

Objectives To bring together: Individuals with spinal disorders

Organisations representing patients with spinal disorders

Charities raising and distributing funds for spinal research

To Discuss How to promote a Spinal Patients’ Interest Group for:

NHS delivery

Political support

Research support

Spinal pain

Spinal deformity

Spinal injury

MAIN THEATRE

13.30-14.00 REGISTRATION Mezzanine Floor - Warwick Arts Centre

14.00-15.30 SESSION 1 Delivery of Clinical Services

Chairs Introduction and Objectives David Chapple & Sara Owen

Spinal Pain

14.05 Nature and extent of the problem Jeremy Fairbank (UKSSB Chair)

14.10 Back Care Brian Hammond

14.15 Spine charities Sean Hughes

14.20 DISCUSSION

Spinal Deformity

14.30 Nature and extent of the problem Jeremy Fairbank (UKSSB Chair)

14.35 SAUK Laura Counsell

14.40 Other scoliosis charities

14.45 DISCUSSION

Spinal injury

14.55 Nature and extent of the problem David Chapple

15.00-15.20 SCI Research and Charities Joost van Middendorp (Stoke Mandeville)

15.20 DISCUSSION

15.30 TEA/COFFEE, NETWORKING, POSTERS AND STANDSMezzanine Floor - Warwick Arts Centre

16.00-17.30 SESSION 2 Delivery of Clinical Services

Research

16.00 Why does spinal research need public support?

Roger Steel (PCPIE Lead NIHR)

16.10 Patient input into research grants, PIS and questionnaires, REC, PPI in studies

Sara Owen

16.15 Charity funding of research James Zorab (BSRF)

16.20 Why not ask the patient what are the research priorities?

Katherine Cowan (James Lind Alliance)

16.25 ROUND TABLE DISCUSSIONTo include “how to mobilise public support for spinal research”

16.45 ROUND TABLE DISCUSSIONWhere do we go from here?Discussion on development of a Spinal Patients’ Interest Group

How to promote a Spinal Patients’ Interest Group for:

NHS delivery

Political support

Research support

17.30 CLOSE

Patients’ Afternoon - Public Meeting about the Spine

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36 37BRITSPINE 2014BRITSPINE 2014

Oral Presentations

Lumbar Degenerative

08.50-09.00The outcome of decompression without fusion for lumbar spinal stenosis in the presence of degenerative spondylolisthesis

Presentation by S Ahmad, A Bhalla, S Turner, B Balain, D Jaff ray

RJAH Hospital Oswestry

Introduction: Lumbar spinal stenosis in the presence of degenerative spondylolisthesis is generally treated by means of decompression and fusion, as per recent SPORT trial results. The role of lumbar decompression alone is not clear. Therefore, the aim of this study was to assess whether patients who undergo a decompression, without fusion, have a favourable outcome.

Methods: This study is a prospective case series of 82 consecutive patients with lumbar stenosis and degenerative spondylolisthesis treated by decompression, without fusion, using a spinous process osteotomy. Surgeons who decided to fuse any such patient at the primary operation were excluded from participating in the study. Blinded observers collected ODI, EQ-5D and VAS scores prospectively. Scores were available for all 82 patients that had surgery. Data was also collected on walking ability, medical and surgical complications and the re-operation rate for any reason.

Results: The mean age was 66 years with a mean follow-up of 1.8 years and a minimum follow-up of one year. The mean pre-operative ODI, EQ-5D and VAS scores were 51, 0.26 and 60 respectively. All mean scores improved post-operatively to 38, 0.54 and 36 respectively. Walking distance improved in 68 patients (83%) and only one had worsening. There were three CSF leaks intra-operatively. Five patients had a return to theatre within 30 days: one for infection, three haematoma evacuations and one for re-repair of CSF leak. Only two patients required revision decompression surgery. Only one patient required a fusion procedure, which was for a post-traumatic lumbar wedge fracture leading to foraminal stenosis.

Conclusion: This study shows that decompression alone for lumbar stenosis in the setting of degenerative spondylolisthesis has good results. Fusion is not necessary in this group of patients. The rate of post-operative instability and subsequent fusion is very low. Our patient outcomes are comparable with the current literature.

09.00-09.10A 7 Year Follow-Up of Dynesys and Interbody Fusion for Discogenic Lower Back Pain: Short Term Hope or Long Term Cure?

Presentation by Budd H, Sharp D, Powell J, Cumming D

The Ipswich Hospital

Purpose: Surgical management of discogenic lower back pain remains a last resort treatment after exhaustive conservative management, specialist back pain management techniques and thorough investigation. In our institution surgery was then considered if provocative discography was suggestive of a discogenic origin and patient expectations were reasonable. These patients were treated with either the Dynesys pedicle screw system or a posterolateral instrumented fusion Methods:

We identifi ed patients from the spinal surgery database treated for provocative discography proven discogenic lower back pain between 2003 and 2008 with pre- and post-operative visual analogue, psychometric and Oswestry Disability Scores available. Final follow-up was by postal questionnaire and telephone interview. Results: Twenty three patients were identifi ed in each group with pre-operative data available and contactable for follow-up. The mean patient age in the Dynesys and PLF groups was 44.6 and 45.4 years respectively. Thirty nine percent and 43% of Dynesys and PLF patients respectively demonstrated a fall in their back pain score of at least half with 3 patients in the Dynesys, and 1 patient in the PLF group reporting complete resolution of lower back pain. No statistical diff erence was demonstrated between the two groups. Conclusions: While our data does suggest gains in discogenic lower back pain relief can be sustained in select patients undergoing surgery we have been unable to prove any advantage to a dynamic stabilisation.

09.10-09.20360-degree versus Posterolateral Instrumented Fusion for Spondylolytic Spondylolisthesis: Does added cost translate to additional clinical value?

Presentation by Budd H, Inaparthy P, Sharp D, Powell J, Chan D, Cumming D

The Ipswich Hospital

Purpose: The surgical management of symptomatic spondylolytic spondylolisthesis demands decompression and fusion of the aff ected level. While there are multiple ways in which this may be achieved we compare the clinical and radiological outcomes of two mainstream treatment modalities used at two large spinal surgery centres, the anterior and posterior interbody fusion (360-degree) and the instrumented posterolateral fusion (PLF). Methods: We identifi ed patients retrospectively from research databases at both institutions having undergone 360-degree fusion or PLF for spondylolytic spondylolisthesis. In addition we performed a cost-analysis of both types of surgery accounting for operative time, in-patient stay and implant costs. Results: Twenty-seven patients underwent PLF and 22 patients a 360-degree fusion with follow-up at a mean of 5 years. While there was a signifi cant diff erence in terms of inter-pedicular distances with greater restoration of foraminal height in the 360-degree fusion group there remains no statistical diff erence in visual analogue scores or Oswestry Disability Index measures between the two groups. Conclusions: A combined anterior and posterior fusion ensures restoration of foraminal dimensions and is potentially biomechanically advantageous. The failure of this to translate into a demonstrable clinical eff ect in the patients analysed may be secondary to extensive decompression during the PLF procedures making additional foraminal height unnecessary. This remains a relatively early follow-up but it is currently diffi cult to justify the more lengthly and complex 360-degree procedure on cost-benefi t grounds.

09.20-09.30Recovery of severe motor defi cit secondary to lumbar disc prolapse: Is surgical intervention necessary? A systematic review

Presentation by Balaji V, Chin K, Tucker S, Wilson L, Casey A

Royal National Orthopaedic Hospital, London

The natural history of motor defi cit due to lumbar disc herniation has been thought to be favourable. However, on closer analysis of seminal articles on this topic, this is not the case for patients with severe motor defi cits (MRC grade = 3). The aim of this study

Wednesday, 2nd April

is to answer the following questions: 1) Is surgical intervention benefi cial in patients with severe motor weakness (defi ned by MRC grade of 3 or less) due to herniated lumbar nucleus pulposus? 2) Does time to surgery from onset of motor weakness infl uence the outcome? 3) Are there any other prognostic factors? A comprehensive search was conducted in MEDLINE and EMBASE from 1970 up to July 2013. Inclusion criteria for studies are: 1) Minimum of three patients aged 18 and older, who had symptomatic herniated lumbar disc prolapse and underwent surgery, 2) Description of pre and post-operative muscle weakness utilising the Medical Research Council (MRC) muscle power grade or equivalent, such that both reviewers could confi dently identify a cohort of patients with at least grade three motor weakness or worse, 3) A minimum of six months follow up. Seven studies were identifi ed with a total of 354 patients. Complete recovery was seen in 38.4% of patients following surgery and 32% following non-operative treatment. Time to surgery, age and grade of motor defi cit were identifi ed as signifi cant prognostic factors in some of the studies. The current available evidence is not robust enough to address the questions posed. We have proposed a framework for future studies.

09.30-09.40Spinal fusion is associated with increased adjacent segment disc degeneration but without infl uence on clinical outcome. Results of a combined long-term follow-up from 4 RCTs

Presentation by Mannion AF, Leivseth G, Brox JI, Fritzell P, Hägg O, Fairbank JC

Schulthess Klinik, Zurich, Switzerland

Purpose: There is ongoing debate as to whether adjacent segment disc degeneration results from the increased mechanical stress of fusion. We analysed long term follow-up (LTFU) data from four randomized controlled trials of operative versus non-operative treatment for chronic low back pain to examine the infl uence of spinal fusion on adjacent segment disc space height as an indicator of disc degeneration at LTFU.

Methods: Plain standing lateral radiographs were taken at 13±4 years follow-up in 229/464 (49%) patients randomized to surgery and 140/303 (46%) to non-operative care. Disc space height and posteroanterior displacement were measured for each lumbar segment using a validated computer-assisted distortion compensated roentgen analysis (DCRA) technique. Values were reported in units of standard deviations (SDs) above or below age and gender-adjusted normal values. Patient-rated outcomes included the Oswestry Disability Index and pain scales.

Results: Radiographs were usable in 355/369 (96%) patients (259 fusion and 96 non-operative treatment). Both treatment groups showed signifi cantly lower values for disc space height of the adjacent segment compared with norms. There was a signifi cant diff erence between treatment groups for the disc space height of the cranial adjacent segment (in both as-treated and intention-to-treat analyses). The mean treatment eff ect of fusion on adjacent segment disc space height was -0.44 SDs (95% CI, -0.77 to -0.11; p=0.01; as-treated analysis); there was no group diff erence for posteroanterior displacement (0.18 SDs (95% CI, -0.28 to 0.64, p=0.45)). Adjacent level disc space height and posteroanterior displacement were not correlated with Oswestry or pain scores at LTFU (r=0.010-0.05; p>0.33).

Conclusion: Fusion was associated with lower disc space height at the adjacent segment after an average of 13 years follow-up. However, the reduced disc space height had no infl uence on patient self-rated outcomes (pain or disability).

09.40-09.50Discogenic Lower Back Pain: A Long-Term UK Clinical Follow-up of the DYNESYS implant

Presentation by Budd H, Sharp D, Powell J, Cumming D

The Ipswich Hospital, Ipswich

Purpose: The Dynesys implant is a pedicle screw based system designed to deliver dynamic segmental stability in patients with degenerative lumbar disc disease restoring interbody kinematics. This study aims to assess the clinical effi cacy of this implant in patients with discogram proven discogenic lower back pain at long-term term follow-up. Methods: We clinically evaluated 23 patients who underwent this procedure for discogram and MRI proven degenerative lumbar disc disease and lower back pain after failure of extensive conservative measures with a mean follow-up of 8.3 years. Pre- and post-operative visual analogue scores and Oswestry Disability Index (ODI) measures were used to assess outcome. Results: Our data demonstrates stable ODI and VAS scores at recent follow-up with an overall mean 20% improvement in ODI and 2.4 point (mean 36.4%) improvement in back pain score (range 0% to 100% improvement). Surgery was at best 54% successful with 87% having some residual symptoms.

Conclusions: While there is clearly a prolonged and sustained functional gain in those successfully treated, beyond 5 years post-surgery, there remains no clear parameter to diff erentiate this group from those that failed to respond and it is therefore not possible to attribute these results to the specifi c implant system used.

09.50-10.00Schizas grading for spinal stenosis reproducibility

Presentation by Catherine Gibson, Harshad Dabke

Salisbury District Hospital, Salisbury

Aim: Schizas et al, in 2010 attempted to provide a valid and reproducible grading system for spinal stenosis. We sought to test the validity and reproducibility of this classifi cation by performing a blinded review of 30 scans.

Method: All consecutive MRI scans requested for stenosis, from the spinal clinic over a 4 week period were reviewed by one independent investigator. The latter was not involved in any patient’s clinical care. Inclusion and exclusion criteria were applied and 30 scans were selected. Inclusion criteria included age 60-80 years, involvement of L4/5 level and exclusion criteria included listhesis (more than grade 1), spinal deformity, other spinal pathology (disc prolapse, metastasis, infection), and previous spinal surgery. The images were anonomysed and each clinician assessed the single axial T2 weighted MRI slice at the level of L4/5 disc space using Schizas’s grading. Responses were submitted to the independent investigator. After one month the scans were shuffl ed by the independent investigator and graded by the clinicians as before. The responses were analysed by the independent investigator who calculated the inter and Intra observer correlation.

Results: We found good correlation between grades reported by the same clinician (Intraobsevor error minimal), R=0.82. The interobersvor coeffi cient of reliability was 0.7, giving a reproducibility on an Interobserver level as 70%.

Conclusion: We conclude that the Schiazis scoring system off ers a reproducible method of grading spinal stenosis but more work is required to assess its prognostic signifi cance.

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BASS Session 1

08.50-09.00Diagnostic yield of whole spine sagittal T2 as an additional MRI sequence in “cauda equina syndrome”

Presentation by Vinay Jasani, Abdul Khader Hamad, Sandeep Konduru, Nik Tzerakis, El Nasri Ahmed, Mark Brown

University Hospitals of North Staff ordshire NHS Trust

Purpose: Cauda equina syndrome (CES) is a clinical diagnosis confi rmed by lumbar MRI scan. Up to 80% of lumbar scans prove to be negative. Pathology elsewhere in the spine could account for the same presentation of symptoms and signs. We evaluate the diagnostic yield of our protocol of a whole spine sagittal T2 sequence MRI scan in addition to the standard lumbar sequences.

Methods: retrospective review of scans requested as protocol for CES over a period of 14 months was undertaken. The radiological report, patient records and scans were reviewed. The MRI sequences were T1, T2 sagittal and T2 axial images of the lumbar spine with an additional T2 sagittal of the cervicothoracic spine. Patients with probable cord pathologies on initial clinical assessment were excluded.

Results: 109 scans were identifi ed 15 had true CES with clinical correlation and underwent urgent surgery (13.7%). 29 had other lumbar pathology (not CES) not needing urgent surgery (26.6%) The T2 sequence identifi ed 8 with pathology above the cauda equina that was clinically relevant (7.3%). 4 had intrathecal space occupying lesions, 2 had metastases, 1 had transverse myelitis and 1 demyelination. 3 out of 8 underwent surgical intervention. None of those identifi ed with additional pathology had other features of cord dysfunction beyond the saddle anaesthesia and or sphincter disturbance. 7 had pathology above the cauda equina that was not clinically relevant (6.4%) This single additional sequence added an average 5 minutes to the scan time. The additional T2 sequence improved the diagnostic yield for relevant pathology from 15 to 23 (53% increase). Conclusion CES presentation has a reported low yield on lumbar spine MRI scanning. Addition of T2 sagittal sequences of the cervicothoracic spine improved our yield of relevant pathology by 53% (7.3% of all scans). The additional diagnoses included surgically relevant ones.

09.00-09.10How Anal are we about “Anal Tone” in patients with suspected Cauda Equina Syndrome

Presentation by Ravi Badge, H Divecha, J Stephenson, I Siddique, S Mohammad, R Verma

Salford Royal NHS Trust

Background: Clinical diagnosis of “Cauda Equina Syndrome” (CES) can be challenging and a delay in prompt diagnosis and decompression results can result in poor outcomes. Hence, it is crucial to identify patients in early stages of CES. Assessment of anal tone with digital rectal examination (DRE) currently forms an essential part of the clinical examination, as well as vital medico-legal documentation, in suspected CES. However its accuracy and relevance is still debatable.Objective - To establish the value of assessment of anal tone in patients with suspected CES.Material and Methods - Our prospectively maintained electronic neurosurgical referrals database, MRI scans and operation notes were studied. Fifty-nine patients who underwent urgent

surgical decompression for CES secondary to disc herniation were identifi ed over a period of two years. All patients included had radiological confi rmation of CES on MRI scan. The main presenting symptoms and examination fi ndings were recorded.

Results: There were 29 male and 30 female patients in this group with an average age of 43.6 years and average BMI of 37.2 kg/m2 (range: 18.2-49.7). 95% of patients presented with radicular pain, 42% with urinary symptoms, 17% with paraesthesia, 8% with foot drop and 1.6% with bowel dysfunction. Absent ankle refl exes (51%) and altered perianal sensation (30%) were the most consistent examination fi ndings. DRE revealed 69% of patients had anal tone present, reduced in 26% and absent in 5%.

Conclusion - In this study of radiologically (MRI) and surgically confi rmed CES, radicular pain and urinary symptoms were the most consistent presenting symptoms. Absent ankle refl exes and altered perianal sensation were the most consistent clinical examination fi ndings. 66% of these CES patients had normal anal tone documented. DRE can be an unpleasant and invasive examination. These results question the usefulness of DRE in helping the practitioner diagnose CES.

09.10-09.20Epidemiology of spinal trauma presenting to a regional neurosurgical centre

Presentation by Difei Wang, Stephen Scullion, Peter Hutchinson, Alexis Joannides, Douglas Hay

Addenbrookes Hospital, Cambridge

Purpose - Spinal trauma represents a signifi cant proportion of neurosurgical emergency activity. On this background, we report the epidemiology and clinical heterogeneity of spinal injuries presenting to the East of England neurosurgical service over a 2-year period.

Methods - Spinal trauma cases were identifi ed from neurosurgical referrals received between August 2011 and 2013, and analysed for injury levels and presenting neurological defi cits. Transferred cases were cross-referenced with local records for details of further management.

Results - 949 trauma cases were identifi ed from a total of 2,298 spinal referrals. 411 involved cervical injuries (C1-4: 254; C5-7: 145; non-specifi c soft tissue injury: 12); 299 thoracic and 289 lumbar injuries. Neurological defi cits were present in 213 cases (22.4%; 26 complete defi cit, 112 incomplete motor, 70 isolated sensory defi cit, 5 autonomic only). Lower cervical injuries were most likely to present with defi cit (33.8%), followed by thoracic (19.6%) and lumbar injuries (17.7%). Complete defi cits were most common in thoracic (6.0%) and lower cervical injuries (4.1%). 476 patients (50%) required further neurosurgical management: 284 were transferred directly as inpatients; 192 managed as outpatients. Lower cervical injuries were most likely to require transfer (40%), followed by lumbar (33.2%) and thoracic (29.2%) injuries. 114 patients underwent surgery. This was most likely in C5-7 injuries (22.8%) and least likely in thoracic injuries (7.5%). Spinal injuries accounted for an average of 1324 bed-days/year (626 cervical; 323 thoracic; 375 lumbar).Conclusions - We demonstrate signifi cant clinical heterogeneity in acute spinal trauma. The majority of cases involve cervical spine injuries, which also account for the largest proportion of bed occupancy. Lower cervical injuries are more likely to present with neurological defi cits and require surgical management.

in 1741 (46.3%) cases; 6 cases had missing operator data. CSF leak occurred in 57 (4.16%) of neurosurgeon operated cases; 5 (2.78%) orthopaedic operated cases; 19 (4.06%) of other surgeon operated cases; and 81 (4.65%) in specialised spine surgeon operated cases. Using Chi-squared test the signifi cance of the variation in incidence of CSF leak between primary operator groups was not statistically signifi cant (P=0.1405).

Conclusions: From the data captured and analysed the rate of durotomy ranged from 2.78% to 4.65% between operator groups with a mean rate of 4.3%. The primary operator credentials do not appear to signifi cantly impact the rate of durotomy in spine surgery.

Keywords: spine surgery; dural tear; durotomy; surgeon credentials; orthopaedic spine surgeon; spinal neurosurgeon.

09.40-09.50A 10 year review of unstable thoracolumbar spinal fractures from Northern Ireland: The associated injuries

Presentation by Stacey Thomson, Harriet Julian, Eugene Verzin, Greg McLorinan, Niall Eames

Royal Victoria Hospital, Belfast

Introduction: Thoracolumbar spinal fractures managed with surgical stabilisation in our regional unit are often associated with other signifi cant injuries. An awareness of these associated injuries aids early diagnosis and management. In these cases delayed and missed diagnoses could result in signifi cant morbidity and mortality.

Objectives: To determine the incidence of associated injuries in patients with unstable thoracolumbar spinal fractures in the national unit in Northern Ireland over a 10 year period.

Method: 481 patients with thoracolumbar fractures underwent surgical stabilisation in our unit over a 10 year period. A sample of 210 cases from this group was identifi ed and all early imaging was retrospectively reviewed. Injury mechanism and all additional injuries were recorded including further skeletal, thoracic, abdominal and head trauma.

Results: Of the 210 cases reviewed, 80 (38%) had an associated injury. Of those 80 with associated injuries 46 (58%) had a single additional injury, 20 (25%) had 2 additional injuries and 14 (18%) had 3 or more additional injuries34 cases (16%) had reported thoracic injuries, 34 cases (17%) further orthopaedic injury, 35 cases (17%) further spinal injury, 13 cases (6%) abdominal trauma, 4 cases (2%) facial fractures and 5 (2%) brain injury / neurological injury. Of those with thoracic injuries, 23 patients (11% of all thoracolumbar fractures requiring stabilisation) had rib fractures and 13 (6%) patients had haemo/pneumothorax. Of the associated orthopaedic injuries upper limb (6%) and os calcis fractures (4%) were most prevalent.The majority of these injuries occurred through road traffi c collisions and falls from height.

Conclusions: A signifi cant number of thoracolumbar fractures that require stabilisation have additional injuries especially chest trauma, further spinal fractures and other orthopaedic injuries.We conclude that a high index of suspicion is required in the assessment of these patients and a multispecialty as well as multidisciplinary approach is required in their management.

09.20-09.30Traumatic central cord syndrome: Neurological and functional outcome, an experience from a regional Spinal Injuries Centre

Presentation by Srinivasa Chakravarty Budithi, Naveen Kumar

MCSI, Oswestry

Purpose - To study the demographics, injury characteristics, neurological and functional outcomes of patients with traumatic central cord syndrome (CCS) who were managed in a regional Spinal Injuries Centre.Methods - Prospective study of 21 consecutive patients with CCS admitted over a two year period. Outcomes were analysed using ASIA Impairment Scale (AIS), Length of Rehabilitation (LOR) and discharge destination. Functional outcome, utilising Spinal Cord Independence Measure (SCIM- III) scores, was measured at commencement of mobilisation and at discharge.

Results - Mean age of patients was 58.77 years (range, 44-81). Fall was the commonest cause (86%), followed by road traffi c accidents (9%) and sports (5%). C5 was the commonest level and AIS C was most common. Eight patients (38%) were treated surgically at the referring hospital and thirteen patients (62%) conservatively at the Centre. Average length of active rehabilitation for CCS was 53 days (9-110). The surgically treated patients had longer LOR, 61 vs 48 days, however this was not statistically signifi cant (p=0.121). Neurological improvement by one AIS grade was noted in 67% of patients. AIS D was commonest (76%) at the time of discharge. Functional improvement was noted in both groups in SCIM scores (Mean 27.75, SD 22.72 for Surgical group and Mean 25.38 SD 23.70 for non-surgical group), however there was no statistically diff erence between the two groups (p = 0.82401). Outcome comparison did not reveal signifi cant diff erence to discharge destination.Conclusion - Outcomes were not signifi cantly diff erent between surgically and conservatively managed Traumatic Central Cord Syndrome.

09.30-09.40Do surgeon credentials aff ect the rate of incidental durotomy during spine surgery: evidence from the international Spine Tango Registry

Presentation by Andreas Demetriades, Nicholas Murray, Colin Nnadi

Western general hospital, Edinburgh

Purpose. Incidental durotomy is a potential complication of spinal surgery which can cause a number of further intra-operative and post-operative complications. The purpose of this study was to determine whether the primary operator’s credentials have any signifi cant infl uence on the incidence of inadvertent durotomy.

Methods. Prospectively collected data of operator credentials in relation to the incidence of durotomy was acquired from the international Eurospine Tango database. The signifi cance of variability and risk factors between operators was measured using the Chi-squared test.

Results. Data from a total of 3764 patients was captured from the Tango registry. Of these 162 (4.3%) had a durotomy. Of the total number of patients the primary operator was neurosurgical in 1369 (36.4%) cases; orthopaedic in 180 (4.8%) cases; other (pre-certifi cation) in 236 (6.3%) cases; specialised spine surgeon

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09.50-10.00Expecting Too Much? A Comparison Of Estimated And Actual Surgical Times

Presentation by John Kiely, Himanshu Sharma

Derriford Hospital, Plymouth

Introduction: Theatre time is an expensive and limited resource, and optimisation of its use is important. Surgical lists are made based on estimates of surgical time, but there is often no guidance of whether this should include the total time used for a case or just the procedure itself. In addition estimates are often not made by the operating surgeon, or without knowledge of who the surgeon will be.

Objectives: Analyse estimated and actual theatre times from Maxillofacial and Neurosurgical departments at the Derriford Hospital to assess what the time estimate is taking in to account, and how accurate thhis estimate is.

Methods: Data collected from 406 patients of estimated, actual surgical, and total theatre time. Routine, urgent and emergency cases included. Trendlines and R-squared used to assess how the estimates compare and how accurate this estimate is. Departments chosen due to sharing theatres, staff and diff erence in type of surgery (longer cases in Neurosurgery)

Results: Neurosurgical estimates usually represented the surgical time only, and total theatre time is over 30% longer than this.Maxillofacial estimates usually represented the total theatre time, with surgical time being about 70% of the estimate.Estimates from both departments were commonly more than 20% incorrect compared to the actual times taken.

Conclusions: How surgical time is estimated varies between departments, making optimal use of theatres diffi cult. It is often inaccurate. With increasing economic pressure on healthcare systems, it is important to monitor and improve our use of this valuable resource.

Keynote Lecture 1

10.00-10.30Complex Cervico-Thoracic Congenital Deformities

Presentation by Joseph Perra

Congenital deformities of the cervical and cervico-thoracic spine are uncommon and to date no clear treatment algorithims have been proposed. A classifi cation system of these deformities has not been adopted, but the methods of Winter and McMaster, seems to be appropriate.

The function of the cervical spine is to position the head in space to optimize the binaural and binocular sensory organs, provide mobility of the head and protect the neural and vascular structures. The eff ects of congenital cervical anomalies may lead to instability, torticollis, plagiocephaly, and a progressive compensatory thoracic scoliosis.

Similar to lumbosacral deformities, occipital cervical and cervico-thoracic have fewer segments to balance or compensate for their deforming elements. Some cases will present at a very young age a with severe torticollis and plagiocephaly requiring treatment which becomes more challenging due to the size of the bones, reserves of the patient and the proximity to sensitive neuro-vascular structures.

Treatment options are limited, bracing is ineff ective in controlling the curve but may assist in maintaining the heads position in space while allowing for some growth pending defi nitive treatment. Since growth potential is frequently limited, if there is moderate deformity and likely to progress, or already known to be progressive -fuse early, don’t let the deformity get too bad, fuse in situ or modest correction with halo or internal fi xation

If very signifi cant and unacceptable deformity consider hemi vertebra excision or vertebral column resection, although clearly more technically demanding and with higher risk

Treatment priorities in order: Neurologic protection, prevent severe deformity, maintain as reasonable neutral position of head/eyes in space and as much as is possible maintain mobility.

Tumour 1

11.00-11.10The Use of Salvaged Blood in Metastatic Spine Tumour Surgery: Dispelling an Old Myth

Presentation by Naresh Kumar, Yongsheng Chen, Aye Sandar Zaw, Qasim Ahmed, Victor Lee, Hee-Kit Wong

University Hospital, Singapore

Background: Catastrophic bleeding is a signifi cant problem in metastatic spine tumour surgery (MSTS). Currently, allogeneic blood transfusion (ABT) is the mainstay for replenishing blood loss, placing an undue strain on blood bank resources and exposing patients to ABT associated side eff ects. Using cell saver (CS) can reduce ABT requirements, however, CS have traditionally been avoided in tumour surgery because of the theoretical concern of promoting tumour dissemination. However, CS has been extensively investigated in patients undergoing surgery for a number of oncological specialities though there is no prior report of the use of CS in MSTS.

Methods: After Institutional Review Board approval, 24 consecutive patients with metastatic spinal tumours from a known epithelial primary and scheduled for MSTS were recruited. During surgery, 15-ml samples of blood were taken from three stages: Stage A - from the operative fi eld prior to CS processing; Stage B - from the transfusion bag post-CS processing; Stage C - from the fi ltered blood after passing through both CS and LDF. Samples were examined using cell block and immunohistochemistry techniques which are highly sensitive and specifi c to identify tumour cells of epithelial origin.Results - Eight cases tested positive for tumour cells in Stage A, three cases positive in Stage B. No sample tested positive for tumour cells in Stage C. In 5 cases, posterior instrumentation without tumour manipulation was performed.

Conclusion: In this fi rst-ever report of cell saver use in MSTS, we have proved that LDF can eff ectively remove tumour cells from blood salvaged during MSTS. Our results are consistent with published results of similar studies performed on CS and LDF use in various oncological surgeries outside the fi eld of orthopaedic surgery. Our results support the fact that CS-LDF combination can be a simple and safe method in reducing ABT in cancer patients undergoing oncological surgeries.

11.10-11.20The fi nancial cost for the surgical treatment of metastatic spinal cord compression

Presentation by Ben Fischer, Hiren Divecha, Saeed Mohammad, Rajat Verma and Irfan Siddique

Salford Royal NHS Trust

Background: The demand for surgery in metastatic spinal cord compression (MSCC) is increasing, thanks to better oncological control, longer life expectancy and earlier diagnosis. Surgical management is complex, high risk and has signifi cant resource implications. To ensure continued development, in line with demand, it is essential the complexity and expense of treating these patients be refl ected by the infrastructure for remuneration to those Trusts delivering these services.

Aim: To establish the short fall between cost and payment for the surgical management of metastatic cord compression.

Methods: Patients treated for MSCC in our institution from November 2010 to August 2011, were identifi ed. HRG codes for their admission and the subsequent payment were obtained. Estimates were made for the cost of inpatient treatment, including: length of stay; theatre time; the cost of implanted hardware; cost of the anaesthetist and the anaesthetic; length of critical care stay; pathology and radiology costs. A calculation was then made to establish the defi cit between total costs and payment.

Results: 19 patients were identifi ed in the time period. The total income accrued was £135,566. However, the total spend for these patients was £472,226. On analysis this fi gure can be attributed to: theatre and anaesthetics (£67,484); pathology (£5,593); radiology (£14,015); implants (£134,900) and other costs (e.g. length of stay) were £248,435. The average cost of treatment was £24,759 per patient, which equates to an average loss of £17,623 per patient, ranging from £8,720 to £59,875.

Conclusion: Remuneration to Trusts for treatment of metastatic cord compression falls signifi cantly short of cost. In our department the short fall is on average £17,623 per patient treated, raising the question for the need to revise the structure of payment, ensuring that patients with this debilitating diagnosis are aff orded optimal treatment.

11.20-11.30The Incidence of Venous Thromboembolic Disease Following 827 Elective Spinal Procedures at a District General Hospital

Presentation by Peter Ralte, Seif Sawalha, Chris Prior, Veenesh Selvaratnam, Yuen Chan, Ian Shackleford, Shashank Chitgopkar

Warrington District General Hospital, Cheshire

Introduction: The risk of postoperative venous thromboembolism (VTE) following elective lower limb orthopaedic surgery is well established. This association is less well defi ned for those undergoing elective spinal surgery. Furthermore, the benefi ts of VTE prophylaxis must be weighed against the risks of postoperative complications such as epidural haematoma formation. This study demonstrates that the incidence of symptomatic VTE following elective spinal surgery is low when mechanical measures alone are used. Methods: Information regarding elective spinal surgeries performed was retrospectively collected from the theatre management system (MEDITECH, Medical Information Technology Inc, MA, USA) and cross referenced using ICD-10 codes to identify those patients that were diagnosed as having had a DVT or PE either as an inpatient or as a readmission.. Results: Between January 2010 and October 2013 eight hundred and twenty seven elective spinal procedures were performed on 776 patients by 4 Spinal Surgeons. The average age of patients at the time of surgery was 51 years. Four hundred and forty two (53%) procedures were performed on women and 385 (47%) on men. The most commonly performed procedures were; 1. Lumbar Microdiscectomy (156, 18.8%), 2. Lumbar Decompression (133, 16.1%) and 3. Lumbar Disc Replacement (131, 15.8%). The average theatre time was 2 hours and 8 minutes. The average length of stay was 5.9 days. Three patients (0.36%) were diagnosed with postoperative pulmonary emboli confi rmed by CTPA (Computed Tomographic Pulmonary Angiography). Two cases occurred prior to discharge and 1 was a readmission. Discussion: The current policy in our institution is for elective spinal patients to receive mechanical VTE prophylaxis with Thromboembolic Deterrent Stockings (TEDS) only. Our study has shown that the incidence of VTE in elective spinal surgery is very low (0.36%) when routine mechanical prophylaxis alone is used. Our study does not support the routine use of chemoprophylactic agents.

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11.30-11.40The role of timing of surgery and comorbidities in metastatic spinal cord compression (MSCC). Is this a useful predictor of neurological recovery? The Oswestry experience

Presentation by Bhalla A, Ahmad S, Balain B, Trivedi J, Jaff ray D Robert Jones and Agnes Hunt

Orthopaedic Hospital Oswestry Shropshire

Purpose: Metastatic cord compression (MSCC) requires critical understanding and prompt treatment. Once diagnosed a plethora of variables are at play to determine prognosis. From current literature the urgent nature of the condition is clear, however little evidence is in place to confi rm the implication of surgical timing. The purpose of this study was to investigate the role of timing of surgery on outcome with regard to neurological recovery. METHODS All patients during a six year period from Jan 2006-Jan 2012 with neurogical involvement were included in the study. Patients who had medical notes & digital images available were divided into operated (n= 40) and non-operated groups (n=26). Review times, imaging, surgery & neurological grades were noted. Outcome measures at 3-6 months included neurological improvement, median survival, complications, admission length, quality of life improvements such as walking/pain relief, and bowel/bladder improvement. RESULTS The average age of operated group was 60.6 years, and non-operative was 63 years. The majority of operated patients had static neurology (30/40 or 75%) with no frankel improvement, of this group 43% had surgery within 48 hours. 8 patients (20%) who showed a 1 frankel grade improvement (Average age 60) were all (100%) operated on within 48 hours; whilst 5% dropped a frankel grade post op (operated 48-72 hours). 46% of operated group reported improvement in QAL measures vs 6% in non-operative; and 10% in operative group reported some improvement in bowel/bladder function vs 0% in non-operative group. The improvement was not related to type of primary tumour. The non-operative group had on average 0.76 comorbidities/per person compared to 0.3/per

person for the operated group. Conclusion: Our study confi rms all eff ort should be made to perform surgery within 48 hours of MSCC with neurological presentation, to maximise the potential for neurological recovery.

11.40-11.50Computer tomography assessed muscle mass as an indicator of longevity in patients with spinal metastasis

Presentation by Harinder Gakhar, Bommireddy R, Calthorpe R, Klezl Z, Williams J

Royal Derby Hospital Uttoxeter Road Derby

Background: Loss of muscle mass (sarcopenia) and function in ageing is associated with reduced functional ability, quality of life and reduced life expectancy. In cancer patients, age related muscle loss may be exacerbated by cachexia and poor nutritional intake. Individuals with widespread disseminated disease are most prone to increasing functional decline, increased morbidity and accelerated death. However subjective assessments of physical performance have been shown to be poor indicators of life expectancy in these patients. Surgical treatment of metastatic spinal cord compression is guided by the life expectancy of the individual. Various scoring systems are in use and they have varying accuracies. AIMS To develop an objective measure to aid calculation of life expectancy in metastatic spinal cancer by investigating the association between objectively measured lean muscle mass and longevity, in 41 patients with known spinal

metastases from all cause primaries. METHODS Lean muscle mass was calculated as total psoas area (TPA)/height (m) 2. Two blinded doctors independently calculated TPA from CT images at the L3 level, performed routinely within 7 days of diagnosis of spinal metastases. Time to death was recorded from retrospective analysis of hospital notes. RESULTS Of patients within the highest tertile for muscle mass 85% were alive at one year, compared with 50% in the lowest tertile. CONCLUSION Death within one year in individuals with spinal metastases is signifi cantly higher in patients with low lean muscle mass at presentation.

11.50-12.00Outcome of surgical management of spinal metastases in a district general hospital

Presentation by E Bagouri, R El-Hassan, AM Hill, L Jagonase, S England, AT Cross, GS Roysam, P Lakshmanan

University hospital of North Durham

Background: Surgical management for spinal metastasis is still controversial. With improvements in the general survival of cancer patients with better oncological management, the need to provide better quality of life for such patients with surgical management increases as well. Normally most resources are concentrated in the University Hospital setting for such multidisciplinary management of these complex patients. We have presented the results of surgical management of spinal metastasis in a district general hospital with multidisciplinary team involvement. Material and Methods Between October 2010 and December 2013, 67 patients with spinal metastasis had surgical management of spinal metastasis in a district general hospital. The data was entered prospectively in a local tumour database in the hospital. Results All the patients had multidisciplinary team involvement and all the cases were discussed in the weekly Spinal MDT. There were 34 men and 33 women with a mean age of 66 years (range 37 to 90 years). The nature of the primary tumour was lung cancer in 15 (22%) patients, renal cancer in 11 (16%) patients, prostate cancer in 9 (13%) patients, and breast cancer in 10 (15%) patients. The indication was curative in 4 patients with primary renal cell cancer and in 2 patients with isolated thyroid cancer metastasis. 15 patients had minimal invasive surgical procedures that included percutaneous pedicle screw stabilisation and cement augmentation procedures. The average neurological recovery was 2 grades in Frankel grading in the neurologically damaged patients. The survival rate after operation was 96% at 30 days, 84% at 3 months, and 60% at one year. Discussion The results are comparable with the outcome published in the literature for the surgical management of spinal metastases. The management of such complex patients can be done in a district general hospital setting provided adequate resources in the form of multidisciplinary team management are available.

BASS Session 2

11.00-11.10Single injection epidural analgesia with local anaesthetic for pain relief following spinal surgery: a prospective randomised study

Presented by Douglas Wardlaw, Amol Rege, Paul Martin, David Knight

NHS Grampian

Introduction: Epidural analgesia is an eff ective way to relieve postoperative pain following surgical procedures on lower limbs and lower abdomen. As the thecal sac is readily accessible during spinal surgery, epidural analgesia becomes an attractive adjuvant for postoperative analgesia. There have been reports in the literature on administration of epidural opiates for relief of postoperative pain following spinal surgery. However they are associated with complications such as urinary retention, respiratory depression, pruritis and patients need additional postoperative monitoring. Epidural instillation of local anaesthetic solution can be a safe option. There are no control studies to evaluate effi cacy of local epidural anaesthetics for postoperative pain relief following spinal surgery. The aim of this study was to assess the effi cacy of epidural analgesia using local anaesthetic for postoperative pain control in spinal surgery.

Methods: Twenty nine patients were randomised to receive either a single injection of epidural bupivacaine or normal saline (placebo) per-operatively prior to wound closure . The anaesthetic protocol and the postoperative pain management was standardised for all patients. There was no diff erence between the two groups with regards to age, gender and type of surgery. The patients were assessed mainly by self-report using the Present Pain Intensity (PPI) and the Visual Analogue Scales (VAS).

Result: The patients receiving epidural bupivacaine needed signifi cantly less systemic opiates postoperatively (p<0.005). There was a signifi cant reduction in the six-hour ratings of PPI (p=0.05) and VAS (p<0.05) scores in the patients receiving epidural bupivacaine. The postoperative hospital stay and need for additional analgesia was not signifi cantly diff erent in both groups. There were no complications and additional monitoring was not required.

Discussion: We conclude that epidural analgesia with local anaesthetic is a safe, eff ective and simple way to control postoperative pain following spinal surgery.

11.10-11.20Endoscopic Epidural Adhesiolysis in FBSS patients with MRI documented epidural fi brosis

Presentation by Stefano Palmisani, Thomas Smith, Adnan Al-Kaisy

Guy’s and St Thomas NHS Trust, London

Background - Endoscopic epidural adhesiolysis is a minimally invasive treatment for chronic back and/or leg pain following failed spine surgery (FBSS), as epidural fi brotic tissue may develop following surgery. However, if epidural fi brosis is evident on MRI, it may be too dense and extensive to be successfully removed with an endoscopic approach. We hypothesis that FBSS patients with MRI documented epidural fi brosis would not benefi t suffi ciently from endoscopic epidural adhesiolysis.

Methods: A prospective clinical audit on endoscopic division

of epidural adhesions in patients with chronic leg and/or back pain not responsive to epidural steroids is ongoing at Guy’s and St Thomas NHS Trust. After accessing the posterior epidural space, proprietary tools (dilation balloon and Molecular Quantic Resonance Technology) tools are employed to dissect/divide any fi brosis under real-time direct vision. No steroids or local anaesthetics are delivered during the procedure. Here we report patient demographics, endoscopic fi ndings, intra-operative outcome and complications, and patients’ satisfaction in a cohort of FBSS patients with evidence of epidural scar tissue in a <12months old lumbar contrast-enhanced MRI.

Results: Twelve FBSS patients suff ering from predominant lower limb (10) or back (2) pain were included, all with epidural fi brosis both on MRI and under endoscopic examination. The endoscopy revealed diff erent grades of fi brosis extension (G4, 7/12 patients; G3, 3/12; G2, 1/12), associated with small or large areas of infl ammation and venous congestion (3/12). Epidural fi brosis was successfully divided from the underlying nerve root/dura in only 6/12 patients (G4, 1/7; G3 3/3, G2 1/1); in one case a dural tear occurred. Following the procedure, 5 patients did not report any benefi t, 4 moderate improvement (<50% pain reduction) and 3 signifi cant improvements.

Conclusions: Technical diffi culty in dividing dense epidural fi brosis and the low success rate achieved suggest that FBSS patients with MRI evidence of epidural scar tissue may not respond signifi cantly to endoscopic adhesiolysis.

11.20-11.30The value of routine postoperative radiographs after elective lumbar spinal fusion surgery

Presentation by Sarah Carter, Syed Ali, Manoj Khatri

Royal Preston Hospital, Lancashire

Purpose: Both intra- and post-operative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however the clinical advantage of routine post-operative images has not been demonstrated. This study aims to explore the usefulness of routine pre-discharge postoperative radiographs in patients undergoing instrumented spinal surgery. Methods Patients (n = 124) who underwent a lumbar spinal fusion were identifi ed from a retrospective database, 58 patients were excluded. Unaltered intra-operative and pre-discharge post-operative PACS images for 66 patients were reviewed and were scored for: i) Quality (0 = non-diagnostic, 1 = suboptimal, 2 = diagnostic, 3 = good quality), ii) Focus (number of vertebra and disc seen), iii) Centering using a numbered (1- 9) grid system, and iv) Rotation. Results 66 radiographs were analysed for i) Quality: 60 AP and 56 lateral intra-operative images while 57 AP and 39 lateral postoperative images were diagnostic, ii) Focus: average number of unnecessary vertebra seen in intra-operative AP and lateral images were 0.89 and 1.09, while on post-operative AP and lateral images were 8.05 and 6.45 respectively, iii) Centering: 48 AP and 51 lateral intra-operative images, while 27 AP and 20 lateral post-operative images were adequately centered and iv) Rotation was adequate in both intra-operative and post-operative images. Conclusion Intra-operative images scored higher in all parameters suggesting that routine post-operative pre-hospital discharge radiographs are unnecessary unless specifi cally indicated and this practice should be discontinued with benefi ts including reduction of radiation dose (and subsequent sequelae), fi scal burden and length of stay.

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11.30-11.40Avoiding Wrong Site Surgery in Spine: Think Head

Presentation by GO Alo, Sanjay Purushothamdas, M Arif

Manor Hospital, Wasall

Purpose: Wrong Site Surgery (WSS) is a rare event; however it has devastating consequences both for the patient and the surgical team. The aim of this presentation is to demonstrate an easy and practical method of avoid Wrong Site Surgery in spinal patients.

Method: We have identifi ed a useful method to ensure that the surgeon is standing on the intended side of the prone patient to avoid Wrong Site Surgery. This method involves confi rming the position of the patient’s head in relation to the position of the surgeon. For a right side surgery, the surgeon stands of on the side of the operating table facing the prone patient and ensures that the patient’s head is to his right hand side. Similarly, for a left side surgery, the surgeon ensures that the patient’s head is to his left hand side. In summary, the side of the surgery, the corresponding hand of the surgeon and the patient’s head are pointing in the same direction.

Results: In our hospital, we have had zero incidence of Wrong Site Surgery in spinal patients by adopting a robust method of communicating via the World Health Organisation Surgical Checklist and standing on the correct side of surgery by our leading hand.

Conclusion: We present a simple and practical method of identifying the correct side of surgery in patients undergoing spinal surgery.

11.40-11.50The Role of Bone Morphogenetic Protein in Revision Lumbar Spine Surgery for Pseudarthrosis: Can We Finally Believe the Hype? A Systematic Review

Presentation by Balaji V, Kaila R, Fonseka S, Patczai M, Divani K, Tucker S, Wilson L

Royal National Orthopaedic Hospital, London

The use of Bone Morphogenetic Protein (BMP) in spinal surgery is controversial. Early studies reported favourable outcomes in achieving spinal fusion with no donor site morbidity when compared to Iliac Crest Bone Graft (ICBG). More recent studies have refuted this and have highlighted the signifi cant complications associated with BMP use. Revision spinal fusion for pseudarthrosis is challenging due to the presence of a hostile fusion environment and potential lack of autogenous bone graft. Hence, this may be an ideal indication for BMP use. The aim of this study is to answer the following questions: 1) Is BMP benefi cial in cases of revision lumbar spine fusion for pseudarthrosis? 2) Does the use of BMP alter the time to achieve fusion? 3) Are there any complications with the use of BMP? A comprehensive search was conducted in MEDLINE and EMBASE from 1990 up to November 2013. Inclusion criteria for studies are: 1) Adult patients aged 18 and older, who underwent lumbar spinal fusion for pseudarthrosis with the use of BMP, 2) Description of pre-operative diagnosis, such that the reviewers could confi dently identify a cohort of patients with pseudarthrosis, 3) Post–operative assessment of fusion for the pseudarthrosis group, 4) A minimum of six months follow up. Nine studies were identifi ed with a total of 170 patients. The studies varied in terms of surgical intervention, type and dose of BMP, graft choice, control arm and radiographic method for confi rming fusion. Fusion was seen in

91.2% of patients following surgery with BMP. None of the studies showed superiority to ICBG. Four studies showed a quicker time to achieving fusion in the BMP group. Complications were poorly described. The current available evidence is not robust enough to address the questions posed. This highlights the need for further high quality studies to defi ne the potential role of BMP.

11.50-12.00Role for day case surgery in patients undergoing lumbar micro-discectomies and decompressions spinal procedures

Presentation by Kristy Kehoe, Ashish Pattni , Anne Moore, Himanshu Sharma

Derriford Hospital, Plymouth

Purpose: Maximising the role of day case surgery has been of paramount importance in recent years. It has the potential to free up inpatient beds, enhance patient experience and dramatically reduce patient waiting times. The aim of this study was to assess whether appropriately selected cohort of micro-discectomies and decompression spinal procedures could be done as day cases whilst maintaining a high level of patient satisfaction and clinical outcome. Materials & Methods: We carried out a retrospective data collection of all spinal orthopaedic day case surgeries undertaken by two surgeons over a year beginning November 2012. Information recorded included age, gender, geographical distribution, use of opiates prior to operation, presence of signifi cant medical conditions and an assessment of pre-operative pain. Site, side, order in the theatre list, duration of operation, time of discharge, weekday or weekend status and peri-operative complications. A telephone survey allowed collection of data indicating post-op problems, improvement of symptoms and patient satisfaction. Results: Of 27 day cases, 6 were lumbar decompressions and 21 were micro-discectomies. Gender distribution was even. There were 2 patients over the age of 60 years. 93% of procedures were carried out either fi rst or second in the theatre list with cases carried out on both weekdays and Saturdays. Discharge time ranged between 15:30 and 21:00. Only one patient had intra-operative complication (incidental durotomy). Two patient’s symptoms progressed following surgery, the rest reported signifi cant improvement in pain. Only one patient contacted for telephone feedback was unsatisfi ed with persistent symptoms, the remaining patients were very satisfi ed and would recommend day case surgery to others. Conclusions: Day case surgery in micro-discectomy and decompression spinal procedures in suitably selected cases appeared to be a safe and cost-eff ective alternative to inpatient management. High patient satisfaction with both clinical outcome and reduced disruption to everyday life was apparent.

Keynote Lecture 2

12.00-12.30Spinal Implant Companies & Spinal Surgeons: The Past, Present & Future

Presentation by Max Reinhardt

Most of the early research on spinal fusions was built on the need to treat scoliosis caused by polio and tuberculosis. These applications were eventually expanded to include trauma, tumours, other spinal deformities, degenerative diseases and spinal fractures. In the US, surgeons began to collaborate with manufacturers with the advent of spinal implants using screws (King, 1944) or rods (Harrington, 1953). In Switzerland, a group of surgeons established the AO (Arbeitsgemeinschaft für Osteosynthesefragen) in 1958 with the goal of changing the treatment of fractures. The AO Foundation was revolutionary as it was one of the fi rst surgeon-driven developments of instruments and implants.

The exponential growth of the spinal implant industry over the past four decades was propelled by clinical needs and advancements in diagnosis. Today, surgeons continue to drive innovation by employing new technologies, developing new surgical techniques and contributing as individual innovators or expert advisors/designers in larger innovation teams with spinal implants companies. With recent economic pressures, there has been a shift from the surgeon/patient customer to include the providers, payers and policy-makers. This shift has caused a drastic change in today’s innovation to move beyond the clinical needs of the patient/surgeon to also address the economic realities of hospitals, governments, and insurance companies. The goals of advancing diagnosis coupled with low cost early intervention to prevent and/or slow the progression of spinal pathologies will result in increased patient satisfaction, reduced cost and improved outcomes. Genetic profi ling, needle-based intervention and pain management may also gain more attention in the near future.

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Tumour 2

15.15-15.25The Use of Intra-operative Salvaged Blood in Metastatic Spine Tumour Surgery: A Systematic Review of the Literature

Presentation by Naresh Kumar, Yongsheng Chen, Aye Sandar Zaw, Qasim Ahmed, Richie Soong, Hee-Kit Wong

University Hospital, Singapore

Background: Metastatic spine tumour surgery (MSTS) is associated with signifi cant blood loss. This blood loss is replenished by allogeneic blood transfusion (ABT) which places an enormous burden on blood banks, and exposes patients to ABT associated risks. Intra-operative blood salvage autotransfusion (IBSA) can reduce ABT requirements in non-tumour related surgery but it is contraindicated in tumour surgery due to theoretical risk of tumour dissemination. Evidence is emerging from diff erent surgical specialties describing the use of IBSA in combination with leucocyte depletion fi lter (LDF) in cancer surgery. However, there is no prior report of IBSA use in MSTS. We wanted to investigate if IBSA is really contraindicated in MSTS and also searched the evidence of the use of IBSA in other oncological surgeries to support its use in MSTS.

Methods: A systematic review of the English literature was conducted using computer searching of Medline, Embase, the Cochrane Central Register of Controlled Trials of articles published between 1 January 1992 and 31 Dec 2012.Results - Our literature search did not provide any publication describing the use of IBSA in MSTS. The literature search only provided the publications describing the use of IBSA in other oncological surgeries. We considered 281 abstracts from the initial search. After consideration by consensus, 30 articles were included in the fi nal analysis. Our systematic review identifi ed 23 reinfusion (1141 patients), 5 non-reinfusion (133 patients) and 2 in vitro experimental studies which all support the use of IBSA and LDF in gynaecological, lung, urological, gastrointestinal, and hepatobiliary cancers.

Conclusions: There is strong evidence that IBSA-LDF can safely remove tumour cells from salvaged blood. IBSA is not associated with any adverse clinical outcomes in patients with cancer surgeries. The reluctance of spine surgeons to use IBSA in MSTS appears to be unsupported. Research is needed to evaluate the application of IBSA-LDF in MSTS.

15.25-15.35The Role of Preoperative Vascular Embolization in Surgery for Spinal Metastases

Presentation by Naresh Kumar, Barry Tan, Priyanka Gahlot, Aye Sandar Zaw

University Hospital, Singapore

Introduction: Preoperative embolization of metastatic tumours aims at reducing perioperative blood loss and improving surgical outcome. This study aims to compare the perioperative degree of blood loss and surgical outcome in spinal metastases, comparing embolized vs. non-embolized, stratifying by primary tumour and surgical procedure.

Methods: This retrospective study analyses patients who were operated on at a tertiary hospital for spinal metastases over a 5-year period. The population was stratifi ed to cases who

underwent pre-operative embolization and those who did not. Cases then were stratifi ed into primary tumour type (Renal, Pulmonary, Colorectal, Lymphoma/Myeloma, Breast, etc.), type of surgery (I:Cervical Corpectomy & Stabilization, II:Thoracolumbar Tumourectomy/Decompression & Instrumentation, III:Thoracolumbar Corpectomy & Stabilization) and both. Intraoperative blood loss was quantifi ed by: haemoglobin concentration drop with consideration of blood units transfused, estimated blood loss intra-operatively. Length of stay (LOS) and duration of surgery (DOS) were also assessed. Age & Race were also analysed for infl uence on outcome.

Results: 98 cases were enrolled (36 embolized, 62 non-embolized, median age 60). Analysis revealed that in myeloma/lymphoma cases, embolization resulted in a signifi cant decrease in blood loss (mean diff erence=1317 ml, p=0.02) and a reduced DOS (94.5 minutes, p=0.04). In colorectal cases, embolization resulted in a reduction in LOS (38.6 days, p=0.04) and DOS (212 minutes, p=0.03). In pulmonary cases, embolization reduced DOS (123.1 minutes, p=0.009). Comparison by type of surgery, embolization reduced the LOS and DOS in type II surgeries (8.42 days, p=0.02; 66.8 minutes, p=0.02) and the DOS in type I surgeries. Combined stratifi cation by tumour and surgery type revealed that embolization is associated with signifi cant reduction in blood loss (2985ml, p<0.01) in the myeloma patients with type II surgery. Increased age resulted in a borderline increase in haemoglobin concentration drop.

Conclusion: Pre-operative embolization in spinal metastases has shown signifi cant benefi ts in LOS and DOS in various groups of cases, but its absolute value in reducing blood loss per se may require further studies to verify.

15.35-15.45Validation of the Oswestry Spinal Risk Index

Presentation by Whitehouse S, Stephenson J, Gregory J, Sinclair V, Tambe A, Verma R

North West Deanery, Manchester

Purpose: The purpose of this study was to validate the recently published Oswestry Spinal Risk Index Score (OSRI) in an external population, to predict survival in patients with Metastatic Spinal Cord Compression (MSCC). Methods We analysed the data of 100 patients undergoing surgical intervention for MSCC at a tertiary unit and recorded the primary tumour pathology and Karnofsky Performance Status to calculate the OSRI. Results Logistic regression models and survival plots were applied to the data in accordance with the original paper. Lower OSRI scores predicted greater survival. The OSRI score predicted survival accurately in 74% of cases (p=0.004). Conclusions Our study has found that the OSRI is a signifi cant predictor of survival at levels similar to those of the original authors and is a useful and simple tool in aiding complex decision making in patients presenting with MSCC. Keywords Spine, metastases, survival, MSCC

15.45-15.55Survival in surgically managed metastatic spinal cord compression

Presentation by Hiren Divecha, Benjamin Fischer, Dmitri van Popta, Ravindra Badge, Irfan Siddique, Saeed Mohammad, Rajat Verma

Spinal Surgery Unit, Salford Royal NHS Foundation Trust

Introduction: Metastatic spinal cord compression (MSCC) can lead

to neurological disability. NICE guidelines for MSCC (CG75, 2008) suggest that surgical intervention should be off ered to patients expected to survive more than 3 months. This decision should be made by a multi-disciplinary team involving oncologists and spinal surgeons, but it can be diffi cult to predict an accurate prognosis.

Aims To determine the post-operative survival in patients treated surgically for MSCC and compare this to an expected survival of 100% at 3 months (NICE CG75). Method All patients who underwent surgical intervention for MSCC at Salford Royal NHS Foundation Trust between 4/2009 and 3/2013 were identifi ed via the theatre management system. Spinal metastases without neurology were excluded. Dates of surgery and death were recorded from the Electronic Patient Record system. Post-operative survival was plotted on a Kaplan-Meier curve. Results Eighty-six patients were identifi ed (54 male, 32 female) with a mean age of 64.2 years (range: 19.3-87.8). Thirty-three represented new diagnoses of cancer. Primary tumour sites were: prostate (16), lung (16), breast (12), myeloma (10), lymphoma (9), unknown (5), colorectal (3), liver (3), renal (2), sarcoma (2), melanoma (2), testicular (1), upper GI (1), urothelial (1), head & neck (1), leukaemia (1) and haemangioma (1). Median survival was 6.9 months (95% CI: 3.3 –10.44). The probability of survival at 3 months was 66% (95% CI: 56–76%); at 6-months, 51% (41–62%); at 12-months, 38% (27–48%).

Discussion Predicting prognosis and selection for surgical intervention in MSCC is diffi cult, as confi rmed by our results. We would expect 100% survival at 3 months if selection were completely accurate. Current scoring systems may be inadequate for purpose, and we suggest the adoption of a simple, validated system (Oswestry Spinal Risk Index) may help guide selection of appropriate patients and therefore apportion resources more eff ectively.

15.55-16.0530, 60, and 90 day mortality in metastatic spinal cord compression (mscc) patients. are we making the right decision to avoid surgical morbidity? the oswestry experience

Presentation by Bhalla A, Ahmad S, Fawdington R, Balain B, Trivedi J, Jaff ray D

Robert Jones and Agnes Hunt Orthopaedic Hospital Oswestry Shropshire

Purpose: Metastatic cord compression (MSCC) requires critical understanding and prompt diagnosis and treatment. Once diagnosed a plethora of variables are at play to determine prognosis. The purpose of this study was to investigate whether the decision making process was the correct one in these patients; or could surgery add to morbidity and mortality of this vulnerable group of patients METHODS All patients referred during a six year period from Jan 2004 to Jan 2010 were included in the study. Patients were divided into operated (n= 103) and non-operated groups (n=96). 1, 3 and 6 month mortalities were then calculated for each group. Other outcome measures included tokuhashi scores, median survival and comorbidities. RESULTS The average age of operated group was 60.7 years, and non-operative was 63 years. The mortality rates for the operated groups at 1, 3, and 6 months were 12.6%, 32% and 50%; The comparative mortality for the non-operative group at 1, 3, and 6 months was 21.9%, 44.8% and 59.4% respectively. The non-operative group had on average 0.76 comorbidities/per person compared to 0.3/per person for the operated group. Average survival for non-operative group was 270 days, and 572 days for operative. CONCLUSION The fi ndings of this study confi rm the high mortality rates in this complex condition reported in literature elsewhere. It confi rms the more

conservative approach taken with patients with multiple co-morbidities/high anaesthetic risk who are treated conservatively is correct as they still have 59% mortality at 6 months. It also importantly highlights, that regardless of treatment modality a mortality of more than 50% at 6 months for all patients presenting with MSCC.

16.05-16.15Posterior stabilisation for metastatic spinal lesions: Radiographical follow-up of 100 patients

Presentation by Harriet Julian, Stacey Thomson, Eugene Verzin, Greg McLorinan, Nagy Darwish, Niall Eames

Royal Victoria Hospital, Antrim

There are no gold standards for surgical stabilisation of metastatic spinal lesions however NICE guidelines state that anterior vertebral body reconstruction should be considered in patients with metastatic spinal cord compression who are likely to survive a year and who are fi t enough to undergo this more prolonged surgery. Standard practice in our unit has been to stabilise metastatic spinal lesions through a posterior only approach. Our rational is that a posterior stabilisation provides suffi cient stabilisation and avoids the addition risks, time, and cost of anterior stabilisation. The aim of this study is to review our posterior stabilisations for metastatic spinal lesions to assess whether a posterior only approach maintains radiographical stability at follow-up. 100 consecutive patients who underwent a posterior only stabilisation for metastatic spinal lesions over a 57 month period were identifi ed. Patient demographics, pathology and spinal levels stabilised were recorded. All post-operative imaging was reviewed. Failures and revisions were recorded. 58 patients were male. The average age at time of surgery was 62 years (range 23 - 84 years). The mean number of levels stabilised was 6 (range 3 – 12). Average number of days from surgery to latest radiographically stable imaging was 186 (range 1 – 1666 days). 3 cases failed due to broken rods, these were detected on plain radiographs between 146 and 515 days after surgery. All 3 patients underwent revision surgery. In 2 patients the posterior stabilisation remained intact however they required additional anterior decompression and cage reconstruction for disease progression (104 and 301 days after initial surgery). Our case series produced a very low rate of failure (3%) and rate of further surgery for disease progression (2%). We would therefore recommend posterior only stabilisation for the management of metastatic spinal lesions. Key words: Posterior stabilisation, spinal metastases.

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BASS Session 3

15.15-15.25Spinal Surgery Procedure Specifi c Consent: An Overdue Evolution of the Consent Process for Specialised Surgery

Presentation by Budd H, Wood R, Sharp D, Powell J, Bhagat S

The Ipswich Hospital

Purpose: Litigation in spinal surgery is increasing and informed consent with thorough pre-operative assessment are crucial to set patient expectations and document the discussion of important and common surgical risks and potential benefi ts. We have performed a survey of spinal surgery centres to ascertain current practice and benchmark against our own consent and pre-assessment processes. Methods: We have surveyed 25 UK spinal surgery departments to determine consent and pre-assessment practice using a web-based survey provider. Specifi cally we have sought to determine whether it is standard practice to use additional procedure specifi c consent forms and information leafl ets as is routine in our institution. We have also attempted to obtain an overview of how the consent and pre-assessment process takes place, the seniority of the staff and time allowed. Results: We have had a 64% response rate to the web-based survey with only 28% of spinal surgery departments routinely using a spinal surgery specifi c consent form in addition to the NHS consent proformas while 70% used procedure specifi c information leafl ets. There was a trend towards larger spinal surgery departments have sub-specialised consent, information provision and pre-assessment processes. Conclusions: In the increasingly litigious climate we believe the evolution of the consent and pre-assessment process in spinal surgery is a necessity. This thoroughly informs the patient, outlines expectations and explains the potential risks of these highly specialised surgical interventions which we believe has minimised patient dissatisfaction at our spinal surgery centre.

15.25-15.35Retrospective review of mechanical thromboprophylaxis in patients undergoing spinal surgery and National Survey of current venous thromboembolism practice in England

Presentation by Lamb JN, Boddice T, Loughenbury PR, Rudol G and Khan AL

Leeds General Infi rmary

Purpose: Chemoprophylaxis for venous thromboembolism (VTE) following spinal surgery remains a contentious issue. This study aims to identify the current VTE prophylaxis practice in units off ering acute spinal surgery in England. We also report the incidence of clinically apparent VTE episodes in our unit where mechanical thromboprophylaxis is used alone. Methods - National survey of 74 trusts off ering acute spinal surgery. Senior clinical staff were contacted by telephone and completed a survey into the routine VTE prophylaxis in their units. There was a retrospective review of adult patients undergoing spinal surgery lasting more than three hours in our institution from 2008 to 2013. The rate of deep vein thrombosis (DVT) diagnosis by Doppler venous ultrasound scan (USS) and the rate of pulmonary embolism (PE) diagnosed on computerised tomography and pulmonary angiography (CTPA) was recorded.

Results: 74 acute hospital trusts off ering spinal surgery were contacted. 61 (82.4%) agreed to participate and 7 were excluded

as they had no protocol for thromboprophylaxis. Of the remaining 54 trusts, 27 (50%) routinely used mechanical VTE prophylaxis and 33 (61%) routinely used chemoprophylaxis. In our unit, 178 patients were identifi ed. All patients received mechanical thromboprophylaxis (calf pumps and compression stockings) alone. Only one had clinical signs of a DVT that warranted USS investigation which was subsequently negative. 4 patients underwent postoperative CTPA and 2 had radiographic evidence of PE. The incidence of PE was 1.1% (2/178).

Conclusions: We report a low rate of VTE in patients undergoing spinal surgery with mechanical thromboprophylaxis alone. It is diffi cult to justify the routine use of chemical thromboprophylaxis, as the numbers needed to prevent one VTE event are extremely large. There is little agreement between approaches to thromboprophylaxis between spinal surgery units in England. A more detailed analysis of mechanical and chemical thromboprophylaxis in spinal patients across multiple units is needed.

15.35-15.45Is Chemical prophylaxis for Venous Thrombo-Embolism needed post- operatively in elective Spinal Surgery? A comparison of practice study and a tertiary centre review of 2472 consecutive procedures over 5 years

Presentation by H Fawi, A Cunningham, K Saba, S Masud, M Lewis, P Davies, J Howes, S James, A Jones, I Chopra, S Ahuja

Spinal Unit, University Hospital of Wales, Cardiff

Venous thromboembolic events (VTE) are a potential complication of surgery. Weighing the risks and benefi ts of chemical prophylaxis dictate the administration practices of our unit. One surgeon (IC) prescribes routinely prophylaxis for all his elective spinal patients- excluding cervical operations. All the other consultants do not routinely, unless the patient is identifi ed as high risk.

Objectives: To establish (1) The VTE incidence in patients with no VTE high risk features undergoing elective spinal surgery, excluding cervical procedures. (2) Assess the diff erence of incidence between the two practice protocols on outcome.

Methods: Consecutive spinal operations (N=2472) between Jan 2007 – Jan 2012 were studied looking for VTE for up to three months postoperatively. Symptomatic pulmonary emboli (PE) were diagnosed by spiral chest CT scans. Deep vein thrombosis (DVT) was diagnosed by venous duplex scans. Further evaluations were based on the study objectives.

Results: All 2472 patients had lower limb compression stockings peri-operatively, and 20.8% (515) of the total cohort received chemical prophylaxis. The incidence of symptomatic VTE in our unit was 0.4%, with 40% Male and 60% Females. There was a prevalence of symptomatic PE of 0.24% (6/2472) and symptomatic DVT of 0.16% (4/2472). None of the VTE episodes were fatal. None of the patients who developed symptomatic VTE were from the cohort who received the chemical prophylaxis in this study. Its use was uneventful. P value < 0.05. Conclusion - This study revealed a prevalence of symptomatic venous thromboembolic events of 0.4%, with a prevalence of PE of 0.24% and DVT of 0.16%. None of the 515 patients who received chemical prophylaxis postoperatively developed a VTE event. P Value < 0.05. This study presents our experience from a major spinal centre. It reveals a low risk of VTE post spinal surgery in general. The decision to use chemical prophylaxis remains under the discretion of the operating surgeon, with proved no post usage complications.

15.45-15.55Effi cacy,safety and cost-eff ectiveness of a same day discharge pathway in spinal surgery

Presentation by Adarsh Nadig, Saeed Mohammad, Rajat Verma, Irfan Siddique

Introduction: There is a desire and a growing trend for safely discharging suitable patients on the same day following single level lumbar decompressive or disc surgery. We wish to present the effi cacy, safety and cost-eff ectiveness of a same day discharge pathway in our practice. Methods: We carried out a retrospective analysis of all patients that underwent single level lumbar disc surgery over a period of two months in the year 2012, following the implementation of a same day discharge pathway with predefi ned inclusion and exclusion criteria. Information about the patient journey from the time of initial referral to the services to discharge upon surgery were collected from the electronic patient records. Trust patient level costings data were compared between those who were discharged the same day to those discharged within 24 hours. Results: In total 72 patients underwent single level lumbar disc surgery over the study period. 65 (91%) of the 72 patients were discharged within 24 hours following the surgery. Among these 61 (85%) patients fulfi lled the clinical safety parameters to be discharged the same day of surgery. In total 18 (25%) patients were discharged on the same day. This identifi ed an opportunity to improve resource allocation and strengthen the effi cacy of the pathway. There were no readmissions among these 18 patients before the scheduled routine follow up. The mean cost benefi t of same day discharge compared with overnight stay was an average of £250 per patient. Conclusion: The implementation of same day discharge pathway can be safe, clinically effi cacious and cost eff ective. With appropriate resource allocation we anticipate signifi cant increase in same day discharges.

15.55-16.05Surgical Site Infection in Spinal operations A tertiary centre review of 4557 consecutive procedures over 5 years

Presentation by H Fawi, M Lewis, J Magol, M Ahmed, P Davies, J Howes, S James, I Chopra, A Jones S Ahuja

Spinal Unit, University Hospital of Wales, Cardiff

Background: Surgical Site Infection (SSI) is a potential risk of any surgical intervention. SSI can pose signifi cant consequences especially in spinal surgery. Previous research showed that there are seasonal variations in the incidence of SSI with numbers peaking in summer months.

Objective: Evaluate (1) incidence of Surgical Site Infection (SSI) for consecutive operations in a tertiary centre, (2) the commonest pathogen, (3) The management in our unit and its long-term outcome, and (4) Eff ect of seasonal change on SSI.Methods - Consecutive spinal operations (N=4557) between Jan 2007 – Jan 2012 were studied looking for SSI using the Centres for Disease Control National Health Safety Network criteria. All patients with SSI positive criteria were included in the study. Further evaluation was based on the study objectives.

Results: 4557 procedures were assessed, of which 30.5% were Decompressions, Thoraco-Lumbar Fusions (Inc. ALIF, TLIF, XLIF, Deg. Scoliosis correction) 25.8%, Cervical operations 18.8%, Scoliosis operations 10.5%, Decompressions and Interspinious spacers 6.9%, and miscellaneous procedures were 7.5%. In

total 8.5% of cases were revision surgeries. The incidence of SSI was 4.9% with 62.1% Male and 37.9% Females. Commonest organisms were Coagulase Negative Staph 31.7%, Staph Aureus 26.8%, Pseudomonas 7%, MRSA 4%, and polymicrobial 30.5%. The average time to detection of infection was 23 days (3-200). Of the positive SSI cases, 9.75% needed surgical debridement. 2.4% needed removal of metal work/Replacement. They all made uneventful long-term recovery. 54.9% of SSI had their operations in the summer months, while 45.1% were operated in the Autumn/Winter months.

Conclusion: Bearing in mind the low infection rate of deep surgical site infections we encountered: Most of the SSI cases were eff ectively treated in our unit by using antibiotics only. The close liaison with our microbiology unit was and remains of paramount importance. There is no clear diff erence found in our study between Summer and Winter months in the rate of developing SSI.

16.05-16.15A Northern Ireland retrospective review of lumbar fusion: effi cacy of intrathecal vs epidural administered anaesthesia on post-operative pain

Presentation by Rakesh Dhokia, Morgan Jones, Eugene Verzin, Greg Mclorinan, Eddie Cooke, Paul Nolan, Alistair Hamilton, Niall Eames

Royal Victoria Hospital, Belfast

Introduction: In Northern Ireland Lumbar fusion surgery is performed under general anaesthetic. In addition to midline and Wiltse approach practices vary for intraoperative anaesthetic administration. We identifi ed 3 groups of patients who received: (A) intrathecal diamorphine (B) epidural diamorphine (C) no diamorphine.

Objectives: To compare pain control, for the fi rst 48 hours post-operatively, in patients undergoing lumbar spinal fusion.Methods - A retrospective review of all patients undergoing elective lumbar spine fusion over a one-year period between October 2012 - 2013. All consecutive patients undergoing lumbar fusion were identifi ed and case notes were reviewed to identify intra-operative analgesic regimen, peri-operative analgesic requirements, pain scores and length of stay.

Result: 66 consecutive patients. 54 % were female. Average age of 52 (29–84), average BMI 30.5 (24-37.3), average length of stay was 6.6 days (2-28 days). 11.5 % had a Wiltse approach with the remaining cases being done via a direct posterior approach. 12 % of surgeons administered local anaesthetic prior to skin incision with 46% of surgeons infusing local anaesthetic locally at the end of surgery. Intra-operatively, (A) 42% of patients received 500 ug Diamorphine intrathecally, (B) 19% received 5mg Diamorphine into the epidural space and (C) 39% of patients did not receive diamorphine. There was no signifi cant diff erence between the time of patients’ fi rst pain trigger and the use of intrathecal or epidural diamorphine. The use of intraoperative diamorphine did not alter postoperative analgesic requirements. The overall pain scores for patients receiving intrathecal diamorphine were initially lower than those patients receiving epidural diamorphine, however this was not associated with lower post-operative analgesic requirements, in the fi rst 48 hours.

Conclusions: The use of intraoperative intrathecal or epidural diamorphine does not appear to signifi cantly alter the postoperative analgesic management of patients undergoing spinal fusion. Those patients undergoing fusion through a Wiltse approach have lower pain scores.

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Oral Presentations

BSS Session 1

08.30-08.40The eff ect of metal density on thoracic and lumbar curve coronal correction in thoracic adolescent idiopathic scoliosis

Presentation by Rushton PRP, Basu S, Cole AC, Grevitt MP

Queen’s Medical Centre, Nottingham, Sheffi eld Children’s Hospital, Park Clinic, Kolkata, India

Purpose: Pedicle screw constructs allow greater curve correction in AIS than hook or hybrid constructs. To date the ideal number of screws per level, or metal density, remains controversial. Current literature is contradictory and mainly composes small single surgeon case series that often fail to consider curve fl exibility. This multicentre international study seeks to assess the infl uence of metal density on coronal curve correction using fulcrum bending correction index (FBCI).

Method: Study design: Retrospective multicentre case series Inclusion criteria: Lenke 1-2 AIS, curve fl exibility assessed by fulcrum bending technique, single stage posterior only surgery, variable metal density up to 80%, >2 year follow up. Outcome measures: Coronal main thoracic and lumbar curve correction, FBCI , metal density (number of instrumented pedicles vs total available).

Surgical technique: Standard technique used in all centres using extra hard titanium-aluminium-niobium alloy 6mm diameter rods (DePuy Synthes, Raynham PA) with reduction of the curvature via cantilever - segmental translation manoeuvres. Implant location and density was according to curve stiff ness and intra- operative bone density. The majority of the implants were on the thoracic curve convexity.

Analysis: Pearson’s correlation coeffi cients for metal density vs FBCI for main thoracic and lumbar curves.

Results: 91 patients, mean age 14 years underwent surgery by one of three surgeons at diff erent centres. Mean preoperative main thoracic Cobb angle of 63° was corrected to 22° (66%) with FBCI of 182% (31-500). Mean preoperative lumbar curve of 39° was corrected to 14° (65%), FBCI of 88% (16-218). Metal density varied from 39-79%, mean 60%. Metal density did not correlate with main thoracic curve correction index (r=-0.05, p=0.6) or correction index for the largely non-instrumented lumbar curve (r=0.07, p=0.6). Conclusions: Increasing metal density does not improve coronal curve correction in AIS. As healthcare costs must be increasingly justifi ed this should be considered by the treating surgeons.

08.40-08.50Does the rib hump return after costoplasty: A surface topography and radiographic review

Presentation by Bowey AJ, Purushothaman B, Lees D, Bowers E, Gibson MJ

Royal Victoria Infi rmary, Newcastle upon Tyne, UK.

Aim: To determine if the rib prominence returns after costoplasty.

Method: Patients with adolescent idiopathic scoliosis underwent plain lateral radiographs and Quantec scans. Maximal rib prominence on the lateral radiograph was defi ned pre- and post-operatively by distance from most posterior aspect of the rib to the facet joint and instrumented rod, respectively. Rib prominence was measured by surface topography Quantec scanning using the Suzuki Hump Sum method. This was then repeated at a later time and by an additional investigator to assess intra-observer and inter-observer variability. The correlation between maximal rib prominence and the Suzuki hump sum was determined. These measures where repeated at 6 months and 1 year post costoplasty.

Results: 11 patients, median age 15 years were evaluated. The correlation coeffi cient between radiograph determined maximal rib prominence and Quantec derived Suzuki Hump Sum was 0.68, R2=0.46. Both inter- and intra-observer showed consistent repeatability. Using lateral radiograph measurements, costoplasty reduced the rib prominence by 55±22% (p<0.001) and 47±28% (p><0.001) immediately and at 12 months following costoplasty, respectively. Assessed by Quantec scanning, rib prominence reduced by 45±18% (p><0.01) and 49±22% (p><0.05) at 3 months and 1 year post costoplasty.

Conclusion: Rib prominence is successfully reduced by costoplasty. However, by lateral radiograph assessment there is some decrease in correction at one year and patients should be counselled of this. Further assessment of the relative merits of these assessment methods is required.

08.50-09.00Spinal deformities in muccopolysaccharidosis type 1 (Hurler’s) patients in the era of Bone Marrow Transplant

Presentation by Tan J, Lui DF, Savage T, Burke N, Kennedy J, Kelly PM, Kiely P, Noel J

Our Lady’s Children’s Hospital, Crumlin, Dublin, Eire.

Purpose: There is a paucity of literature regarding spinal deformities in Mucopolysaccharidoses type 1(MPS1) Hurler’s syndrome patients. A gibbus has been commonly associated wit MPS1 and suggestion that its presence in less than one year of age is pathognomonic. We analysed the Irish population of Hurler’s to evaluate the incidence and delineate radiological parameters in the era of Bone Marrow Transplant (BMT).

Methods: Between 1989 and 2013 we retrospectively analysed 51 MPS1 patients. Lateral whole spine x-rays were reviewed. Thoracic(T5-T12) kyphosis, lumbar(L1-S1) lordosis Cobb angles and angles at the gibbus was measured. Cervical spine pathology incidence was noted.

Results: 51% male and 49% female patients. Average age at review was 12.65 years. Mean age of radiological evidence of a spinal pathology was 7months. Documented incidence was 94%. Mean levels of fi rst recorded gibbus was 10months most commonly at L1 followed by L2. Mean cobb at gibbus 56degrees. Mean thoracic kyphosis 14degrees. Mean lumbar lordosis 32degrees. Cervical subluxation was present in only 1 but 28% had hypoplasia of the odontoid. 5 required casting or brace. 3 patients had growing rods inserted and 1 went on to fi nal posterior spinal fusion. Mortality was 23%( mean age of 17months ).

Conclusion: An overwhelming majority have a gibbus often diagnosed radiographically before the age of one . Orthopaedic intervention maybe be required when there is progressively

Thursday, 3rd April

worsening gibbus kyphosis of >40 degrees for improvement of quality of life due to increasing life expectancy in the era of BMT.

Keywords: MPS1, Hurler’s, gibbus, kyphosis, cobb angles, management

09.00-09.10Validation of the Perdriolle technique for measurement of apical vertebral rotation using digitally stored and enhanced radiographs

Presentation by Grannum S, Landham P, Mckay, G, Patel MS, Hutchinson J, Hutchinson J, Nelson I

Frenchay Hospital, Bristol, UK

Title: Validation of the Perdriolle technique for measurement of apical vertebral rotation using digitally stored and enhanced radiographs

Aim: Axial vertebral rotation is among the most important parameters for the evaluation of spinal deformities. The Perdriolle technique for assessment of apical vertebral rotation has previously been shown to be a valid and reliable technique. In line with the advances in the fi eld of digital radiography, hospitals have been increasingly using picture archiving computer software (PACS) systems. Our aim was thus to validate the technique for assessment of apical vertebral rotation using the Perdriolle torsionometer on acetate, together with digitally stored and enhanced radiographs using picture archiving computer software (PACS) systems.

Method: apical vertebral rotation was assessed in 30 consecutive scoliosis whole spine digital AP radiographs using the perdriolle torsionometer. Measurements were performed by 3 consultant spinal surgeons, 3 spinal surgical fellows and 3 orthopaedic house offi cers in order to establish utility of the technique across all grades of doctors. Measurements were repeated by each observer on 2 separate occasions one week apart. Results were subjected to weighted kappa statistical analysis.

Results: Inter-observer agreement was greater than 0.8 across all 3 grades measured. Intra-observer agreement was also greater than 0.8, across all observers, indicating excellent agreement.

Conclusion: Our data confi rms the reliability of the perdriolle torsionometer on acetate for assessment of apical vertebral rotation using digitally stored and enhanced radiographs across all grades of doctors

09.10-09.20Bone Rate With rhBMP-2 Versus Autologous Iliac Bone in PEEK Cages for Anterior Lumbar Interbody Fusion

Presentation by Charles-Henri Flouzat Lachaniette, Amir Ghazanfari, Charlie Bouthors, Alexandre Poignard, Jérôme Allain

Hôpital Henri Mondor, Créteil, France

Purpose: Autologous iliac crest bone graft (ICBG) is the gold standard of materials for spinal fusion. Bone graft substitutes such as rhBMP-2 have been developed to address the issues related to morbidity of ICBG harvesting. The objective of this study is to compare the bone fusion rates between ICBG and rhBMP-2 by examining thin-cut CT-scan images at one-year follow-up. Method: 51 patients (62 levels) who underwent video-assisted minimally invasive single or two-level anterior interbody

lumbar fusion (ALIF) in our institution between September 2008 and January 2012 were included in this series. Radiolucent cages were inserted in all of the cases. Each cage has a middle beam delimiting 2 chambers. Grafting was performed as follows: one chamber was fi lled with autologous ICBG and the other chamber was fi lled with 6 mg of rhBMP-2. Thin-cut CT-scan multiplanar reconstruction analyses were performed to assess the rate and quality of bone fusion.

Results: Fusion was observed in 55 levels (88.7%) with signifi cant diff erences in fusion rates with rhBMP-2 and ICBG (71% vs. 88.7%) (P=0.001). Osteogenesis in the rhBMP-2 chamber had a centripetal pattern in all the cases leaving a central void in 97.7% of the cases representing 38.3% of the surface of the cage (range, 0–80.3%). In the ICBG chambers, resorption of the graft was present in 44.4% of the cases representing 9.8% of the surface of the cage (range, 0–52.2%).

Conclusion: RhBMP-2 was inferior to ICBG on terms of rate and quality of bone fusion in one- or two-level ALIF.

09.20-09.30Improving the quality of lateral whole-spine radiographs used in spinal deformity surgery

Presentation by Simon Craxford, Michael Gale, Oliver Stokes, Masood Shafafy

Queens Medical Centre, Nottingham

Purpose: Several senior members of our department expressed the opinion that many of our whole-spine radiographs taken for preoperative planning were subjectively of poor quality and diffi cult to measure. We therefore set out to objectively assess the quality of our whole-spine radiographs against an agreed criteria, and to determine if poor quality radiographs translate to decreased inter observer reliability of measurements. Methods We carried out a retrospective review of 152 consecutive lateral whole-spine radiographs taken in our hospital. Adult and paediatric radiographs were included as this fairly represents our case mix. We evaluated the radiographs against a criteria previously agreed with the radiology department (whole spine seen, adequate x-ray penetration, occiput visible, chin visible, sacrum clearly seen, femoral heads visible, femoral heads superimposed, arms crossed in correct position). The radiographs were scored out of a maximum of 8 points. 6 post-FRCS spinal fellows then measured the pelvic incidence on subsets of the best and worst scoring radiographs 3 times. Inter-observer reliability of these measurements was then compared for good (radiographs that scored 8) and bad radiographs (radiographs that scored <5). Results We found that only 32% (48/152) of radiographs studied met all of the criteria agreed for a lateral whole-spine fi lm. 34% and 20% met 7 or 6 out of 8 criteria respectively. Inter-observer reliability (measured by intraclass correlation) was signifi cantly higher for “good” (0.988, p><0.01) radiographs than for “bad” (0.512 p=0.12). Conclusions Only a third of our lateral whole-spine fi lms meet the criteria agreed in the literature. A poor quality fi lm, judged against our agreed criteria, is associated with a lower inter-observer reliability when performing measurements. We therefore suggest a list of 8 criteria that a whole-spine radiograph should meet in order to ensure reliable measurements can be made.

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09.30-09.40Incidence of neural axis anomalies on magnetic resonance imaging in early onset and adolescent idiopathic scoliosis patients

Presentation by Amit Zaveri, Kiran Divani, Kia Rezajooi, Matthew Shaw, Alexander Gibson

Royal National Orthopaedic Hospital, Stanmore, UK.

Purpose: To determine the incidence of neural axis anomalies as found on magnetic resonance imaging scans (MRI) of the whole spine in pre-operative early onset and adolescent idiopathic scoliosis patients.

Method: We retrospectively analysed the MRI scans and radiographs of the 300 most recent patients with idiopathic scoliosis operated on for correction in our unit, looking for any neural axis anomalies. All scans were reported by senior consultant musculoskeletal radiologists. Inclusion criteria were those patients aged 18 years old or under, pre-operative for scoliosis corrective surgery, with idiopathic curves, and no neurological symptoms or signs. Any patients with concomitant syndromes, neuromuscular disorders, or any abnormal neurological clinical fi ndings were excluded from the study. We also analysed case notes of all patients found to have intraspinal anomalies to document their further management.

Results: From our retrospective analysis of the 300 most recent idiopathic scoliosis cases that went on to have corrective surgery, we found a total of 32 patients had intraspinal anomalies discovered on MRI scanning. All 32 cases (100%) were discussed at our Neurosurgical Multi Disciplinary Team Meeting, in the presence of a senior spinal neurosurgeon. The commonest intraspinal anomaly was Chiari type I malformation (13 patients, 41%). The second most common intraspinal anomaly was persistent central canal (10 patients, 31%). A total of 4 patients (12.5%) required neurosurgical operative intervention (3 foramen magnum decompressions and 1 cord de-tethering).

Conclusion: In the largest such UK study to date, we conclude that the incidence of intraspinal anomalies in early onset and adolescent idiopathic pre-operative scoliosis patients is around 1 in 10 (10.7%). We recommend that all idiopathic scoliosis patients should have a pre-operative MRI scan of the whole spine, and all intraspinal anomalies discovered should be directly discussed with neurosurgeons in a multi-disciplinary fashion.

SBPR Session 1

08.30-08.40Prevalence of Vitamin D defi ciency in patients presenting with low back pain in an outpatient setting

Presentation by Kwang Chear Lee, Asif Khan, Stephen Longworth, Philip Sell

Leicester General Hospital, Leicester

Introduction: There has been a recent surge in the interest of the role of vitamin D in chronic musculoskeletal pain however there are limited studies that have investigated the link of vitamin D hypovitaminosis with low back pain. The aim of our study was to determine the prevalence of low vitamin D levels in patients who present with low back pain in an outpatient setting in the UK.

Methods: Data was collected retrospectively from computerised databases of all patients who presented with low back pain from a single spinal consultant’s outpatient clinic and have had serum levels of 25-hydroxycholecalciferol (25-OH vitamin D) requested. Data of these patients were collected from hospital electronic and paper records and analysed against their serum 25-OH vitamin D levels.

Results: Data on 229 patients was collected over an 18 month period. 19.7% of patients presenting to the spinal outpatient clinics had severe 25-OH vitamin D defi ciency (less than 15 nmol/L) compared to 2.6% of 3132 non-spinal outpatient clinic patients (p<0.001). However, the percentage of patients with defi cient (15 to 30 nmol/L) but not severe defi ciency was similar in both groups (37.6% versus 38.3%). There was no signifi cant diff erence in the incidence of vitamin D defi ciency whether a surgical or non-surgical pathology was present or not (p=0.62).

Conclusion: We have found no link between vitamin D defi ciency and low back pain in this study. Vitamin D defi ciency is a common comorbidity in Leicester. (233 words not including title and headings)

08.40-08.50Identifi cation of obstacles to recovery in secondary care

Presentation by Kwang Chear Lee

Leicester General Hospital, Leicester

Introduction: Yellow fl ags are psychosocial indicators which are associated with a greater likelihood of progression to persistent pain and disability and are referred to as obstacles to recovery. It is not known how eff ective clinicians are in detecting them. Our objective was to determine if clinicians were able to detect them in secondary care.

Methods: 133 new referrals in a specialist spine clinic completed the Oswestry Disability Index (ODI) and a range of other validated questionnaires including the yellow fl ag questionnaire adapted from the psychosocial fl ags framework. Clinicians blinded to the patient data completed a standardized form to determine which and how many yellow fl ags they had identifi ed. Results The mean age of the patients was 48 years. The mean number of yellow fl ags per patient was 5 (range: 0-9). Clinician sensitivity in detecting yellow fl ags was poor, identifying only 2 on average. The most common yellow fl ag reported by patients was “Fear of movement or injury” (87%), and this was also the yellow fl ag

most frequently missed by clinicians, being identifi ed correctly in only 44% of patients. Overall sensitivity of clinicians was poor at only 38%. Sensitivity was highest for the yellow fl ag “Anxiety” (57%), and lowest for “Pre-occupation with health” (20%). Interestingly, registrars had a higher overall sensitivity compared to the consultant (46% versus 27%, p=0.012). Overall specifi city of clinicians was moderate at 73%. Patients who reported more yellow fl ags were more likely to score higher on their ODI (Pearson correlation=0.48, p<0.01) and Modifi ed somatic perception scores (Pearson correlation=0.45, p><0.01). They also had poorer Low Back Outcome Scores(Pearson correlation=-0.447, p><0.01).

Conclusion: Clinician sensitivity in detecting yellow fl ags is poor. Improved identifi cation of obstacles to recovery may improve outcomes. Clinicians may improve detection of these obstacles by having a simple set of questions completed by the patient.

08.50-09.00A potential minimally invasive nucleus pulposus replacement based on peptide/glycosaminoglycan hydrogels

Presentation by Danielle E Miles, Sami Tarsuslugil, Elizabeth Mitchell, Nik Kapur, Ruth K Wilcox and Amalia Aggeli

School of Chemistry University of Leeds, Leeds

Purpose: To develop a novel, minimally invasive therapy for nucleus pulposus replacement without the need for major surgical incision. Methods: A versatile class of patented self-assembling peptides based on natural amino acids were examined and the design criteria for a suitable hydrogel established. The peptides were analysed using a series of complementary techniques (NMR, FTIR, CDUV, TEM & rheometry) to determine their behaviour at the molecular and nanoscale levels. The material properties were further optimised by mixing with glycosaminoglycans (GAGs) to mimic the vital biological osmotic pumping action and aid in swelling pressure. These solutions can be switched from fl uid to gel inside the body. A range of systematically varying peptide solutions were injected in a bovine caudal model to assess the potential to remain at the treatment site and to restore disc mechanics.

Results: It was found that systematic changes in peptide structure led to aggregates with diff erent morphologies, self-assembly profi les and mechanical properties. Another exciting fi nding was strong evidence that the mechanical properties of the gels can be controlled by peptide design and GAG ratio, allowing up to a 10,000 fold variation in the stiff ness. The presence of the peptide greatly reduced the leakage of injected GAG and a denucleated disc repaired with a peptide:GAG gel was found to restore the mechanical behaviour to that of a disc with a healthy nucleus intact.

Conclusion: A gel material has been developed that can be injected through a narrow bore needle and has the potential for nucleus pulposus replacement.

09.00-09.10Morphometric analysis of facet joint arthropathy using high resolution SPECT/CT – a prospective clinical study

Presentation by Vittorio M Russo, Ranju T Dhawan, Adrian TH Casey

NHNN, Queen Square, London

Purpose:Assess the value of hybrid SPECT/CT imaging in patients with low back pain (LBP). We evaluate the correlation of SPECT/CT patterns with the degree of facet joints degeneration on CT scans.

Methods:100 consecutive patients with (LBP) were prospectively evaluated. Patients with known or suspected malignancy, trauma, infectious processes and previous surgery were excluded. The eff ect of LBP on the daily quality of life was assessed using the Oswestry disability index (ODI). Pathria grading system was used to score the severity of facet joints arthopathy on CT scans. Patterns of metabolic activity on hybrid SPECT/CT imaging were correlated with the degree of facet joints degeneration.

Results:100 patients were included (59 females, 41 males, mean age of 56.2 years). Mean ODI score was 38.5% (range 8-72%). A total of 800 facet joints from L2-3 to L5-S1 was examined. 403 facet joints (50.3%) appeared normal or with mild degenerative changes (Pathria grade 0-1), 272 (34%) had moderate degenerative changes (Pathria grade 2) and 125 (15.6%) were severly degenerated (Pathria grade 3). 51% of patients had scintigraphically active facet joints on hybrid SPECT/CT imaging. 57.3% of Pathria 3 grade facet joints resulted scintigraphically active while 42.7% were quiescent on SPECT/CT; 2.5% and 9.2% of Pathria 0-1 and Pathria 2 respectively were active. 70% of the active facet joints on SPECT/CT were found at L4-5/L5-S1 levels.

Conclusions: Facet joint arthropathy is a common cause of LBP. The ability of hybrid SPECT/CT imaging to precisely localise metabolically active facet joints may provide signifi cant improvement in the treatment of patients with LBP. In this study we demonstrate that metabolic activity in the facet joints is not always correlated with the degree of degeneration found on CT. There would be more than 50% of “wrong or missed targets” if considering treating facet joint arthropathy only on the basis of CT fi ndings.

09.10-09.20Self-organising biomimetic collagen/nano-HA/GaG scaff old for spinal fusion

Presentation by Aman Sharma, Hua Ye, Jeremy Fairbank, Jan Czernuszka, Christopher Lavy

Nuffi eld Orthopaedic Centre, Oxford

Purpose: Degenerative conditions of the spine are common throughout the world, leading to chronic and often severe back pain. Spinal fusion often has a role to play in treatment, but can be associated with complications such as pseudoarthrosis and donor site pain in cases where an autograft is used, therefore driving the search for alternative treatments. We are studying the recapitulation of the extracellular matrix of normal bone using an osteoconductive scaff old together with osteoinductive agents, in an attempt to develop a novel targeted therapy for use in degenerative and age-related vertebral conditions.

Methods: A biomimetic strategy was employed to fabricate a

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collagen/hydroxyapatite/glycosaminoglycan scaff old. This was characterised using scanning electron microscopy (SEM), atomic force microscopy (AFM) dynamic scanning calorimetry (DSC), micro-CT, multiphoton spectroscopy and mechanical testing. Scaff olds were seeded with human mesenchymal stem cells (hMSCs). Proliferation assays and quantitative gene expression (using RT-PCR) were performed to study stem cell growth and osteoblastic diff erentiation (levels of BMP-2, RUNX2, osteocalcin).

Results: A self-organising collagen/nano-hydroxyapatite/GAG scaff old was fabricated and micro-CT and SEM confi rmed a heterogeneous, porous structure with a mean pore diameter of 150-200μm. Viable hMSCs were visualised within the scaff old and RT-PCR showed an increase in expression of markers of osteogenesis. The denaturation temperature of the scaff old was 52degreesC, therefore above that of body temperature, refl ecting potential protection from proteolytic enzymes. Conclusion We have successfully synthesised a novel collagen-based scaff old using a biomimetic strategy. This is biocompatible and promotes bone formation. Further studies, including in vivo work, are required to assess the clinical utility of this scaff old.

09.20-09.30Does spinal manipulation change cervical inter-vertebral motion?

Presentation by Jonathan Branney and Alan Breen

Institute for Musculoskeletal Research and Clinical Implementation, Bournemouth

Purpose: To determine if spinal manipulation is associated with changes in cervical inter-vertebral motion (IV-RoM) and if any changes are related to patient outcomes.

Methods: Thirty patients with neck pain and 30 matched controls had their cervical inter-vertebral motion (C1/2 – C5/6) measured in fl exion and extension by quantitative fl uoroscopy (QF). Patients had spinal manipulative treatment over four weeks and completed pain and disability questionnaires at baseline and follow-up. Controls had no treatment and both groups had QF assessments at four weeks. Intra-subject variation in segmental IV-RoM over four weeks was determined in controls.

Results: There was a weak (Rho=0.39, p=0.043) positive correlation between the number of manipulations received and the number of levels that increased in range beyond their intra-subject variation. Segments that had at least four manipulations increased their range more than any change in controls. However, only one hypo-mobile segment increased its range above intra-subject variation, and there was no relationship between clinical improvement and change in IV-RoM.

Conclusion: Spinal manipulation was associated with increased inter-vertebral motion in a dose-response manner, but this was not correlated with outcomes.

Keywords: Spinal manipulation; spinal manipulative therapy; neck pain; cervical; inter-vertebral motion; quantitative fl uoroscopy; kinematics?

09.30-09.40Levels of Evidence of Spinal Research Published in the Highest Impact Medical Journals

Presentation by Bakur A Jamjoom, Aimun A Jamjoom, Abdulhakim B Jamjoom

University Hospitals Coventry and Warwickshire, Coventry

Introduction: It is recognized that the level of evidence (LOE) of clinical research and its publication in a journal with a high impact factor (IF) is a refl ection of its quality. It is also recognized that the highest impact medical journals (HIMJs) are the New England Journal of Medicine (NEJM) (IF=51.66), the Lancet (IF=39.66), the Journal of American Medical Association (JAMA) (IF=29.98) and the British Medical Journal (BMJ) (IF=17.22). LOE of spine research published in major spine journals was examined in the literature in a recent publication. In this study the authors assess LOE of spine research that was published in the four HIMJs over a 5 year period.

Methods: The four HIMJs’ web sites were searched and original research articles directly related to the spine that were published during 2009-2013 were identifi ed and reviewed. LOE was assessed using the Oxford scale. The fi ndings were compared to the LOE of spine research published in spine journals from the literature.

Results: Of the screened 4807 articles, 28 (NEJM 3, Lancet 9, JAMA 5, BMJ 11) satisfi ed the inclusion criteria. LOE of the studies was I in 71%, II 7% and IV in 21%. The articles were multi-centred in origin in 75%, related to therapy and economics in 82% and focused on degenerative spinal disease in 50%. A signifi cant diff erence relating to the LOE and type of article was observed between articles published in HIMJs and those in spine journals. Articles citation numbers correlated with journals’ IF and year of publication.

Conclusions: Few spine research articles are published in the four HIMJs every year. These tend to have greater proportion of articles with higher LOE and related to therapy and economics. Spine research that is published in HIMJs is likely to be cited more and make an added impact on the medical community.

Keynote Lecture 3

09.40-10.10Spondylolisthesis and Spinal Stenosis, a review of surgical interventions

Presentation by Wilco Jacobs

The objective of this overview was to evaluate the available evidence from systematic reviews on the eff ectiveness of surgical interventions for spondylolisthesis and spinal stenosis resulting in LBP or low back related irradiating leg pain and/or paraesthesias. We searched Cochrane databases and Pubmed for evidence on the eff ectiveness of surgical interventions for spondylolisthesis and spinal stenosis. Included were systematic reviews with at least a comprehensive search strategy and a risk of bias assessment. We included comparisons of surgery versus conservative care and of diff erent surgical techniques compared to each other. The quality of the systematic reviews was evaluated using AMSTAR by two reviewers independently. We also identifi ed gaps in the evidence from systematic reviews. For spondylolisthesis, surgery appears to lead to better improvement in pain and clinical outcome compared to conservative treatment, while the diff erent surgical techniques show no diff erences or confl icting results. Fusion appears to result in better clinical outcomes than decompression, while the choice for any type of fusion, either instrumented or non-instrumented cannot be made based on current evidence.

For spinal stenosis, reviews that examined surgery versus conservative treatment found that surgery appears to result in better outcomes (leg pain, disability) with regard to conservative interventions, but the evidence is heterogeneous and the underlying methodology of low quality. IPD appears to result in a better ZCQ outcome compared to conservative interventions, but there is insuffi cient evidence for the comparison between other surgical interventions. No evidence was found that fusion is a useful addition.

Keynote Lecture 4

11.00-11.30When disc height decreases – the vertebrae increase

Presentation by Tapio Videman

The goals was to measure the concordant changes in morphology of the discs and vertebrae during 5, 10 and 15-year follow-ups. Among a general population sample of 232 men that had been scanned in 1992-1993, 105 men were re-examined 10 years later. Mean age at 15-year follow-up was 63 years. Image analyzing software was used to measure distances and areas of interest of mid-sagittal and mid-axial spine images. The disc heights decreased at 5 years by 3.4% (0.4 mm) and 3.3 % (0.4 mm) and at 15 years 8.7 % (1.0 mm) and 11.3 % (1.3 mm) in the upper and the lower discs respectively (p<0.001). While not clear after 5years, vertebra heights increased in mean by 3.1 % (0.8 mm) in the upper lumbar levels and by 4.7 % (1.1 mm) in the lower vertebrae after 15 years (p<0.001). Vertebra height increases were associated with disc narrowing (P=0.001). The mean annual shortening of the lumbar spine L1-S1 block was 0.13 mm/year, which was in line with the mean standing height, which decreased little (174.7 cm at baseline and 174.4 cm at follow-up).

Discs and vertebrae degenerate or remodel in concert: decreases in disc height appear to be compensated, in part, by accompanying increases in adjacent vertebra heights. The mechanism behind this novel fi nding and its implications require further study. One could speculate that disc height narrowing could produce increased instability and tension at the disc fi ber insertions of the adjacent vertebral endplates stimulating bone growth.

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SBPR Session 2

11.30-11.40A comparison of (1) mri muscle fat content in psoas and erector spinae muscles and (2) patient reported outcome measures in patients with lumbar degenerative disc disease, L4/5 degenerative spondylolisthesis and L5/S1 lytic spondylolisthesis

Presentation by Andrew Cunningham, Kiroless Saba, Michael McCarthy

University Hospital Wales, Cardiff

Purpose: To determine whether the muscle fat content on MRI is associated with patient reported outcome measures (PROMs) in patients with three low back complaints; degenerative disc disease (DDD), L4/5 degenerative spondylolisthesis (4/5 DSPL) and L5/S1 lytic spondylolisthesis (5/1 LSPL).

Methods: 30 patients from each category were randomly selected from the senior author’s prospective PROMs database. MRI scans were available in 29 DDD, 29 4/5 DSPL and 21 5/1 LSPL. At set magnifi cation, a grid was randomly applied to the mid discal T2 weighted axial scans at the L3/4, 4/5 and 5/1 levels. The number of points touching muscle and fat in the left and right psoas and erector spinae (multifi dus and longissimus) muscles were recorded. This data was then compared to the PROMs data. Results There was no diff erence between the left and right sides in any of the groups. There was no diff erence in PROMs between the three groups. There was no association between muscle fat content and any of the PROMs in any of the groups (VAS back, VAS leg, ODI, walking distance, PHQ9 and GAD7). The muscle content in the 4/5 DSPL group was signifi cantly less than the other 2 groups. Patient age in the 4/5 DSPL group was signifi cantly higher than the other 2 groups (p<0.01). Muscle content signifi cantly correlated with increasing age in the erector spinae muscles at all levels in all three groups (all p><0.01). Psoas muscle content was not associated with increasing age except in the L3/4 and L5/1 levels of the 4/5 DSPL group (p><0.05).

Conclusions: Muscle fat content in the erector spinae and psoas muscles does not appear to be related to PROMs. Muscle content decreases with age.

11.40-11.50Assessment of Signs and Symptoms in the Diagnosis of Cauda Equina Syndrome – a Prospective single unit study

Presentation by J Tomlinson, O Evans, R Michael, L Breakwell, N Chiverton, A Cole

Northern General Hospital, Sheffi eld

Purpose: Cauda equina syndrome (CES) is a potentially disabling problem if not diagnosed and treated promptly. Several retrospective studies have suggested urinary dysfunction and altered perianal sensation have high sensitivity but not specifi city in cauda equina syndrome. This study prospectively assessed the reliability of symptoms and signs in diagnosing Cauda equine compression to establish if certain fi ndings are more reliable predictors of CES.

Methods: All patients referred to the spinal unit with suspected CES were assessed by the admitting registrar and positive symptoms and signs recorded using a 20-point template. Subsequent MRI scans (if requested) were then assessed to confi rm cauda equina compression. Clinical fi ndings were

then correlated to scan fi ndings to establish if certain signs and symptoms more reliably suggest a diagnosis of CES.

Results: Between February 2012 and 2013, 62 patients were referred with suspected CES. The male: female ratio was 1:1.3 with a mean age of 48 (22-86 years). 52 patients (84%) underwent MRI scanning and 5 patients (10%) were found to have cauda equina compression necessitating surgery. The symptoms and signs more likely to indicate cauda equina compression were urinary retention; decreased anal tone and peri-anal sensation; altered genital sensation and loss of catheter sensation. Back pain, faecal soiling and urinary incontinence were poorer indicators.

Conclusion: Accurate prospective diagnoses of CES may be improved by assessing post voiding bladder scanning and catheter/genital sensation. We would recommend that MRI remains the gold standard investigation as per previous studies. The presence or absence of the symptoms describe may be useful in the prioritizing of patient scans but further work with larger numbers of patients is needed to confi rm this. It is important to acknowledge all suspected cases of CES should be imaged – this study does not support ruling out CES on clinical fi ndings alone if suspicion is present. A large scale national study with large patient numbers would be needed to establish if CES can be ruled out on clinical fi ndings alone - and even then this would remain questionable.

11.50-12.00Spinal Injection Therapy Performed By Physiotherapists- A 2 Year Evaluation of 145 Trans Foraminal Epidural Steroid Injections

Presentation by Patrick Hourigan. Helen Challinor, Andrew Clarke

Spinal Unit, RD+E Hospital, Exeter

Purpose: We report the outcome of 145 Trans Foraminal Epidural Steroid Injection’s (TFESI’s) procedures performed by physiotherapists in our unit.

Methods: 145 patients underwent lumbar TFESI’s (74 with nerve root pain secondary to disc prolapse, 71 from spinal stenosis.) 2 year outcomes for conversion to surgery or additional injection therapies have been assessed.

Results: The waiting time for spinal injection therapy has been reduced to a mean of 4 weeks from listing.Of the patients with disc prolapse, 26 of 74 (35%) underwent surgical management. 34 of 74 (46%) had not required any further medical treatment. 10 of 74 (14%) had undergone a repeat injection and 7 of these had relief of symptoms such that they could be discharged. Of the patients with spinal stenosis (lateral recess or foraminal), 22 of 71 (31%) underwent surgical management. 31 of 71 (44%) had not required any further medical treatment. 12 of 71 (17%) had undergone a repeat of the injection and 6 of these (50%) had suffi cient relief of symptoms such that they could be discharged. No major complications have occurred in the 145 procedures.

Conclusions: Spinal injections delivered by ESPs have comparable outcomes to those of medical colleagues. The majority of patients achieve long-lasting symptomatic control without recourse to surgical management.Surprisingly, the number of patients with the chronic complaint of spinal stenosis converting to surgery was less than the number of patients with disc prolapse, which normally has a more promising natural history and tendency to self-resolve.

12.00-12.10The eff ect of a functional restoration programme on disability, physical function and pain

Presentation by Gareth J Venn, Graeme Paul-Taylor, Valerie Sparkes and Jennifer Moses

University Hospital of Wales, Cardiff

Purpose: The substantial economic burden and clinical signifi cance of chronic low-back pain (CLBP) has led to the development of Functional Restoration Programmes (FRP) (NICE 2013) which aim to improve the physical, psychological and overall wellbeing of CLBP patients (Poirandeau et al, 2007).This study examined the impact of a FRP on participants’ measures of disability, physical function and pain.

Methods: Data collected on an FRP over an eighteen month period was retrospectively analysed. The sample consisted of 52 participants with CLBP of three months plus duration: 21, male, 31 female, age: 42.7(10.7) years who were referred from numerous sources. The Oswestry Disability Index (ODI) reported participants’ levels of disability (Ostelo and deVet, 2005).Sit to stand (STS) data was utilised as a responsive measure of physical function (Andersson et al, 2010).Numerical rating scale data was recorded as a measure of perceived pain (Mod VAS) (Ostelo and deVet, 2005).

Data: was collected pre, post intervention (3 week programme) and at follow up (>3-6 months). Results Analysis of variance revealed a signifi cant diff erence (p<0.05) between pre, post and follow up measures on the ODI and STS measures. Analysis of Mod VAS revealed a signifi cant diff erence (p><0.05) between pre-programme scores and follow-up only. Conclusions Despite self-reported pain levels being unchanged post-intervention, participants reported signifi cant improvements in perceived disability and physical functioning which were maintained and associated with reduced self-reported pain at follow-up. The results suggested that participation in the FRP led to signifi cant improvements in all domains measured with maintenance of those improvements at follow-up. Keywords Functional Restoration Programme, Chronic Low Back Pain, Self-Reported Disability, Physical Function.

12.10-12.20A systematic review of interventions for preventing and treating low-back and / or pelvic pain during pregnancy

Presentation by Sarah Dianne Liddle, Victoria Pennick Keywords: Back and pelvic pain, pregnancy, systematic review

University of Ulster, Antrim

Purpose: To assess the eff ects of interventions for preventing and treating LBP and / or pelvic pain during pregnancy. Methods: The Cochrane Pregnancy and Childbirth and Back Review Groups’ Trials Registers were searched to July 2012 for randomized controlled trials (RCTs) of any intervention. The review authors independently assessed risk of bias and extracted data. The quality of the evidence was assessed using criteria outlined by the GRADE Working Group. Results: Twenty-six RCTs (N = 4093) were included. The quality of the evidence for LBP interventions was either low or very low. Exercise, in general, signifi cantly reduced pain (six RCTs, N = 543), disability (two RCTs, N = 146) and sick leave (one RCT, N = 241); however, there was no diff erence in either pain relief or functional improvement between two types of pelvic support belt, or between osteopathic manipulation (OMT), usual care, or sham ultrasound. There was moderate-

quality evidence that acupuncture signifi cantly reduced evening pelvic pain better than stabilizing exercises, and low-quality evidence that acupuncture was signifi cantly better than sham for improving evening pelvic pain and function, but not average pain. For lumbo-pelvic pain, low-quality evidence suggested that exercise signifi cantly reduced sick leave (two RCTs, N = 1062) and when combined with manual therapy and education, improved pain and function; acupuncture improved these outcomes more than usual care or physiotherapy, particularly if started at 26- rather than 20-weeks’ gestation, as did OMT. There were confl icting results for prevention of pelvic or lumbopelvic pain. Adverse events were minor and transient. Discussion: Despite the addition of 18 new trials to this review, the quality of evidence on this topic has not improved since 2007; no outcomes were supported by high-, and only three by moderate-quality evidence. Clinical heterogeneity of population, interventions, comparisons and outcome measures precluded most meta-analyses.

12.20-12.30What happens to patients with symptoms of cauda equina syndrome, but a negative MRI scan?

Presentation by Simon Craxford, Ashish Khurana, Julie Turner, Magnum Tsegaye

Queens Medical Centre, Nottingham

Purpose: During an average week at our spinal unit, several patients will present with signs and symptoms of cauda equina syndrome (CES). Some of these patients will have CES excluded by MRI scan and be discharged back to their GP. We sought to discover the outcomes of such patients.

Methods: We retrospectively surveyed 100 patients who had been assessed in our spinal unit for possible cauda equina and had a negative MRI scan. Urinary symptoms were assessed using the ICIQ-LUTS (qol) questionnaire, UI score and OAB score. Back symptoms were assessed using the Oswestry Low Back Disability Index (ODI). Depression and somatic symptoms were assessed using the Modifi ed Somatic Perception Questionnaire (MPSQ) and Modifi ed Zung Index (MZI). Patients were also asked if they were currently working, had undergone a procedure on their back and if they had any outstanding litigation relating to their symptoms.

Results: Of the 100 patients identifi ed, 3 had died. Surveys were sent out to the remaining 97. 33 people returned completed surveys, giving a return rate of 34%. 22 (66%) reported that they were troubled in some way by urinary incontinence. Average ODI was 55 (range 14-82). 24 patients (72%) were unemployed or had taken early retirement. Average MPSQ and MZI were 18 and 33 respectively. 25% had undergone either surgery or a procedure on their back. Only one patient was perusing litigation. Worryingly, 42% stated that their symptoms were worse or much worse than one year previously.

Conclusions: While fewer than expected patients returned the survey, it is clear that a proportion of patients assessed for CES with negative imaging will have signifi cant symptoms several months following their initial presentation. We recommend that appropriate follow up including urological and pain services should be provided for these patients to ensure their problems are not overlooked.

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12.30-12.40A spinal ‘Enhanced Recovery and Education Programme’ for elective lumbar discectomy, decompression and fusion: The eff ect on patient length of stay

Presentation by Matthew Brown, Sarah Parr, Theresa Maunganidze, Peter Dyson, James Langdon

West Herts Hospitals NHS Trust, Hertfordshire

Keywords: education, recovery, spine, decompression, discectomy ABSTRACT Purpose A novel spinal enhanced recovery and education programme (EREP) was implemented to expedite rehabilitation and reduce length of stay for patients undergoing elective lumbar discectomy, decompression and fusion surgery. A multidisciplinary team, including a Specialist Nurse and Extended Scope Practitioner, provide patients with pre-operative surgery-specifi c education, in addition to in-patient and post-discharge support.

Methods: We performed a prospective review of hospital length of stay for patients treated with a spinal enhanced recovery and education programme (EREP) since implementation in September 2012. A comparative cohort before programme implementation was also reviewed.

Results: Twenty-six patients [mean age 56.6 years; male 10, female 16] treated using the spinal EREP were compared to 26 pre-EREP patients [mean age 54.8; male 9, female 17]. The mean day of discharge was reduced from post-operative day 2.0 to day 1.7. Although not statistically signifi cant, it refl ects a trend in reduced length of stay that continues.

Conclusions: Enhanced recovery programmes are well established for hip and knee arthroplasty. The implementation of a spinal enhanced recovery and education programme for patients undergoing elective lumbar spine surgery helps to reduce length of stay. Pre-operative patient education is associated with improved patient satisfaction and this is being audited at present. Spinal surgery departments across the United Kingdom could make signifi cant fi nancial savings and improve patient satisfaction through the development of similar programmes.

BSS Session 2

11.30-11.40Complications in Spinal Deformity Surgery in the United Kingdom. Five year results of the annual British Scoliosis Society National Audit of Morbidity & Mortality

Presentation by Hiren M Divecha, Irfan Siddique, Lee M Breakwell, Peter A MillnerOn behalf of the British Scoliosis Society (Corporate Author).

Purpose: To provide a 5-year, national overview of corrective spinal deformity surgery in the United Kingdom. Methods: Since 2008, the British Scoliosis Society has collected predefi ned data on spinal deformity surgeries carried out by its members. Participating units collect and submit annual anonymised data pertaining to the number of deformity surgeries performed, age groups, aetiology (idiopathic versus non-idiopathic), mortality, deep infections and neurological defi cit (complete, incomplete without resolution and incomplete with resolution). Overall aetiology proportions and complication rates were calculated, as well as funnel plots with control limits of individual complication rates by cases performed.

Results: Between 2008 and 2012, 9295 corrective spinal deformity procedures were performed. 4445 (48%) were recorded as idiopathic and 2917 (31%) as non-idiopathic. There were a total of 339 complications (3.6%). Deep infections occurred in 222 (2.82%), incomplete neurological defi cit with resolution in 59 (0.65%), incomplete neurological defi cit without resolution in 29 (0.32%), complete neurological defi cit in 12 (0.13%) and mortality in 17 (0.19%).

Conclusions: The complication rates reported in this study compare well with previously published studies. These reported results will hopefully serve to provide a benchmark for units in the UK providing corrective spinal deformity surgery to allow individual units to compare their complication rates against national averages and to provide national complication fi gures to aid in the consenting process of patients. Use of a spinal deformity registry, such as the British Spine Registry, is required to ensure ongoing service development and optimal healthcare provision.

11.40-11.50A new medical device in the treatment of Early Onset Scoliosis (EOS): An audit of the reimbursement process

Presentation by Babur Mahmood, Arvindera Ghag, Colin Nnadi

Nuffi eld Orthopaedic Centre, Oxford, UK.

Purpose: NHS England and Monitor have recently published a National Tariff Document to refl ect changes in the Payment by Results system (PbR). Previously it had not adequately reimbursed specialist spinal services. The new system allows for local variations to National Tariff s to refl ect the true cost of treatment. A new and expensive medical device has been used in the treatment of early onset scoliosis in our institution. We performed an audit to assess whether the new National Tariff confers any fi nancial advantages compared to the old PbR system with regards to reimbursement for the device.

Method: From November 2012 to November 2013 the medical records of 10 patients were retrospectively reviewed. All cases had EOS. Average age was 5.2 years Health Related Group description (HRG) was HRO1C, HR01B and HR02Z in 6, 1 and 2

patients respectively. 1 HRG was scoliosis. 8 were elective and 2 semi-electives. The Operation and Population Censuses Code (OPCS1) was V411 (8) and V418 (2). OPCS4 codes were Z665 (4), Z664 (3) and Z668 (1). Results: Average Tariff on old PbR system was £30,546 and on the new system it was £37,143. This was suffi cient to cover previously calculated implantation costs of £33000. Five variables, which enhanced the tariff , were identifi ed: 1. Age (< 18 years) 2. Specialised Service “Top-up” (Spinal surgery) 3. Presence of Comorbidities 4. Complications 5. Market Forces Factor

Conclusions: The new National Tariff system if applied correctly approximates to the true cost of treatment in EOS using a new medical device.

11.50-12.00Reducing the Pelvic Incidence through a S2 Pedicle Subtraction Osteotomy with Sacral-Pelvic Disarticulation and Anterior Pelvic Rotation

Presentation by A Khurana, NA Quraishi

Queens Medical Centre, Nottingham, UK

Purpose: We describe a novel approach using S2 pedicle subtraction rotation osteotomy with sacral-pelvic disarticulation and anterior pelvic rotation to reduce pelvic incidence(PI) and improve sagittal vertical axis(SVA).

Illustrative case: A 48 year-old woman with incapacitating low back pain and previous L5/S1 postero-lateral fusion for spondylolisthesis, underwent the procedure upon failure of non-operative treatment. Her standing radiographs showed PI 113°, lumbar lordosis 53° and SVA +18cm. A MRI showed lateral recess stenosis at L4/5. She had a markedly increased PI and hyperlordotic lumbar spine. Further lordosis with lumbar osteotomy would lead to dysfunctional sagittal alignment with the body’s centre of mass falling well behind the hip axis.

Procedure: The surgery was performed in 2 stages. Pedicle screws (L2-S1) with two bilateral iliac wing screws were inserted. TLIF were performed at three levels with revision decompression at L4/5. The 2nd stage was performed 7 days later and included decompression from S1 to S3 and PSO through S2. A 30° wedge was removed from one sacroiliac joint to the other and then longitudinally through each sacral ala. This disarticulated the upper sacrum from pelvis. The caudal iliac screws were connected with a transiliac bar which was utilized to rotate the pelvis anteriorly relative to the spine. This indeed ‘opened’ the PSO. A 4 rod construct was then used to gradually close the PSO with subsequent fi xation to iliac wing and pedicle screws in a caudal to cephalad direction.

Results: The PI decreased from 113° preoperatively to 82° postoperatively. Her ODI improved from 68 pre-operatively to 45 post-operatively and 34 at 1 year. Her sagittal balance improved from +18cm to +6cm.

Conclusions: This report shows that PI can be altered, however, due to anterior rotation of the pelvis, there is tendency for the lumbar lordosis to reduce. There was satisfactory radiological and clinical outcome.

12.00-12.10Multi- level Anterior Cervical Discectomy and Fusion: Clinical and Radiological outcomesPresentation by A Khurana, C Martini, BM Boszczyk, MM Tsegaye Royal Gwent Hospital, Newport, Gwent

Purpose: The aim of this study was to analyse the outcomes of multi-level (2 or more levels) anterior cervical discectomy and fusion (ACDF).

Methods: We performed a retrospective cohort study of all patients operated for multiple level ACDF in this tertiary spinal unit between May 2007 to Dec 2012. Patients were identifi ed from the electronic database in the unit and the theatre ORMIS system. Clinical records and radiological investigations were reviewed for all patients. Clinical outcome measures used included prospectively collected pre and post-operative ODI scores. Radiological outcome measures included pre and post-operative lordosis in the cervical spine (C2-C7) and in the fused segment. Radiographs were reviewed independently by two assessors to decrease inter-observer errors. Results Consecutively operated 80 patients were included in the study. This included 42 males and 38 females. The mean age was 56.9 years (range 18 to 89 years). The mean follow up was 13 months (range 3-31 months). One patient was operated for four level fusion, 16 for three level and 63 for 2 level fusion. The mean pre-operative ODI was 56% (range18-84) which improved to 37% (range 0-70) (p=0.03) on the fi nal follow-up. The mean pre-operative cervical (C2-7) lordosis was 5.6° which improved to a mean of 16.8° post-operatively (p=0.034). Similarly, the mean lordosis in the segment fused improved from 0.4° pre-operative to 7.8° post-operatively ( p=0.027). Complications included two patients with vascular injury, two with transient hoarseness, one each with permanent recurrent laryngeal nerve injury, transient dysphagia and plate pull-out leading to oesophageal laceration. Revision surgery was required in 4 (5%) patients due to implant failure or non-union.

Conclusion Multiple level (2 levels or more) ACDF helps to regain the cervical lordosis and improves the clinical outcomes. Revision rates for non-union and implant failure were approximately 5%.

12.10-12.20The Management of Thoracolumbar Deformity in the Mucopolysaccharidoses

Presentation by Stephen AC Morris, Elizabeth Ashby, Ramesh Nadarajah, Tom Ember, Deborah Eastwood, Stewart Tucker

Great Ormond Street Hospital, London, UK.

Background: The mucopolysacchiradoses represent a group of storage disorders caused by enzyme defi ciencies. They are characterised by a range of skeletal manifestations, including abnormalities around the thoracolumbar junction. Small series in the literature have reported on these fi ndings. We present one of the largest series on spinal deformity in mucopolysaccharidosis (MPS) patients and the requirement for surgical intervention.

Materials and Methods: 194 paediatric patients with mucopolysacchiradoses were reviewed by the metabolic team in a tertiary referral centre. 107 of these patients underwent spinal imaging in this unit during a 10 year period from 2003 – 2013. Data collected included the number of patients with each subtype of MPS, the number with thoracolumbar spinal deformity, the presence of thoracolumbar vertebral morphological abnormality, and the number of patients

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progressing to surgery. The need for revision surgery was also reviewed.

Results: 107 of the 194 patients underwent spinal imaging. This included 45 patients with MPS I, 23 with MPS II, 20 with MPS III, and 19 with MPS IV. Deformity was present in 75 patients (70%) and was most common in MPS I (80%) and IV (89%). Morphological abnormality was seen in 54 patients (50%) with involvement in 89% of MPS IV patients but only 5% of MPS III patients. 29 patients (27%) required surgery for progressive deformity not controlled by non-operative measures. 22 patients underwent anterior fusion, 4 had posterior fusion, and 3 had anterior and posterior procedures. 5 patients (23%) required further procedures for progressive adjacent deformity.

Discussion: MPS is an uncommon aetiology for thoracolumbar deformity. However, a large number of these patients have abnormal vertebral morphology and it is important to understand the optimum methods of managing progressive deformity. Further work on the role of enzyme therapy and its eff ect on spinal deformity in MPS will help guide the non-operative measures available to clinicians.

12.20-12.30Incidence of False Positive Spinal Cord Monitoring Alerts in Surgery for Early Onset Scoliosis

Presentation by OM Stokes, E Bayley, R Burton, DA Rothenfl uh and H Mehdian

Queen’s Medical Centre, Nottingham

Introduction: Spinal cord monitoring alerts are decreases in amplitude of somatosensory evoked potentials (SSEPs) or motor evoked potentials (MEPs) and they direct the surgical team to the potential for neural injury. Alerts may be secondary to curve reduction, hypotension, or unknown causes. When surgical or anaesthetic manoeuvres fail to return the amplitudes to their pre-alert levels, this is either associated with post-operative abnormal neurology (true positive), or normal neurology (false positive).

Methods: All cases of deformity correction for early onset scoliosis, 2003 - 2012, had dual- or mono-modality spinal cord monitoring. The data was prospectively collected identifying spinal cord monitor alerts, surgical or anaesthetic measures to address the alert and the post-operative neurological status of the patient.

Results: 65 procedures in 54 patients, mean age 4 years at time of surgery. Eleven for neuromuscular scoliosis (NMS), 23 congenital (CS) and 31 idiopathic (IS). 29 procedures were monitored with SSEPs and MEPs. There were 12 monitoring alerts, 7 in procedures with dual modality monitoring. Alerts occurred 4 times in IS (13%) and 8 times in CS (35%), with no alerts in NMS. In all of the IS, there was a normalization of the monitoring with intra-operative manoeuvres and no post-operative neurological defi cit. In CS 5/8 of the alerts responded to surgical or anaesthetic measures, while 3/8 cases had persistent abnormalities. One was a true positive with a neurological defi cit post-operatively. The false positive rate, when a spinal cord monitoring alert occurs, was 25% in CS versus a 0% false positive rate in IS.

Conclusion: Spinal cord monitoring has become a standard of care for spinal deformity correction. Technological advances have led to increased sensitivity of the equipment. False positive monitoring alerts are signifi cantly more frequent in the correction of CS. We postulate that this is due to the frequency of abnormalities of the neural axis and vascular supply

12.30-12.40A multicentre case series of muscle necrosis of the leg following spinal surgery with MEP monitoring - A cause for concern?

Presentation by Kiran Divani, Andrew O Brien, Sean Molloy, Jayesh Trivedi, Alexander Gibson

Royal National Orthopaedic Hospital, London

Purpose: There are no reports in the literature linking MEP monitoring to muscle necrosis. We present a multicentre retrospective review of a case series of fi ve patients who developed ‘compartment syndrome’ of the leg following spinal surgery with MEP monitoring with an aim of identifying possible causative factors.

Methods: All data was collected contemporaneously and retrospective analysis was performed. We then arranged for a multidisciplinary review of the cases including surgeons, anaesthetists, radiologists, neurophysiologists and theatre and ward nursing staff .

Results: Four of our fi ve patients underwent a posterior single stage spinal deformity correction and one patient underwent excision and posterior instrumentation for a chondrosarcoma. All patients were operated on by three diff erent surgeons, on diff erent operating tables/mattresses in the prone position and with diff erent anaesthetic techniques. The only common factors were free-running MEPs and mechanical calf pumps. Three patients underwent surgical decompression of their compartments and two were treated expectantly. All patients had confi rmed intracompartmental changes on MRI consistent with compartment syndrome and one had intracompartmental pressure monitoring which confi rmed the diagnosis. Previous cases in the literature have related to malpositioning on the Jackson table or use of the knee-chest position for surgery. This was not the case for our patients.

Keywords: Spinal surgery, compartment syndrome, muscle necrosis, motor evoked potentials

12.40-12.50Flat backs in adolescent idiopathic scoliosis: is anterior surgery being overlooked?

Presentation by Bowey AJ, Purushothaman B, Lees D, Gibson MJ

Royal Victoria Infi rmary, Newcastle upon Tyne, UK.

Aim: To determine the change in thoracic kyphosis and lumbar lordosis with anterior and posterior corrections in adolescent idiopathic scoliosis.

Methods: Consecutive patients with adolescent idiopathic scoliosis underwent single stage anterior or posterior instrumented corrections between 2011 and 2012. Pre- and post-operative radiographs were analysed using the Lenke classifi cation, coronal and sagittal measures and prone traction views.

Results: 20 females, mean age 14 years (range, 10-17) were included. Pre operatively, the thoracic kyphosis did not diff er between those treated by an anterior or posterior approach (mean 23.6º vs. 25.4º, p=0.09). Post-operatively, the mean thoracic kyphosis cobb angles were 24.6º and 16.5º for an anterior and posterior approach, respectively. The change in cobb angle was signifi cantly diff erent between the groups (p<0.05). For all

patients, the lumbar lordosis pre- and post-operatively remained within the normal range (30-60º). There was a greater change in those treated with a posterior vs. anterior approach (14.7º vs. 4.9º, p><0.05).

Conclusion: Anterior correction recreated the normal thoracic kyphosis. Posterior surgery had a lordosing eff ect resulting in ‘fl at’ backs. The loss of normal sagittal balance may result in junctional kyphosis and late spinal morbidity. The role for anterior surgery in maintaining normal sagittal balance should not be overlooked.

Keynote Lecture 5

13.55-14.40The infuse aff air: How BMP-2 came to America

Presentation by Eugene Carragee

Keynote Lecture 6

08.45-09.15Is surgery for adult spinal deformity cost-eff ective?

Presentation by Wilco Peul

The BackgroundIntermittent Neurogenic Claudication (INC) is a disabling walking disorder caused by lumbar degenerative facet artrosis leading to stenosis. With aging populations spinal stenosis becomes an important societal issue, as people do want to stay as mobile as possible. The increasing incidence of INC results in a rising rate of low back surgery, in some countries even surpassing the high and variable rates of herniated disc surgery for sciatica.

The ProblemWhile simple bony decompression of posterior spine elements is the golden standard surgical treatment for spinal canal stenosis, recent years presented a rising use of implants in (inter) national registry systems. This varies between simple, but expensive, use of Interspinous Implants versus complex reconstructive surgery for adult spinal deformity. Although the use of pedicle screw implants to reconstruct deformed lumbar spines seems plausible to prevent further deformity, one can question the associated costs and unclear added value to elderly patients. In addition to the costs, they bear a serious risk of local and systematic complications. Besides stakeholders’ questions about cost-eff ectiveness of spinal implants for INC, variation of surgery rates exists between and within countries.

The SolutionWhile research group randomise patients to look for the holy grail of evidence based spinal surgery, this seems diffi cult in adult spinal deformity. The use of prospective data registry systems is needed for quality of care audits, but scientifi c research questions might also be answered by careful analysis. Comparative Eff ectiveness Research (CER) might lead to answers.

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Special Poster Presentations

Surgical

09.15-09.2046. A Multi-Centre Retrospective Cohort Study of Spinal Osteoid Osteomas: Surgical treatment and local recurrence results

Presentation by N A Quraishi, S Boriani, P Varga, A Luzzati, Z L Gokaslan, M G Fehlings, C Fisher, M Dekutoski, L Rhines, J Reynolds, C Bettegowda, N Kawahara, R Williams

Queen’s Medical Centre Nottingham

Introduction: pinal osteoid osteomas are uncommon benign primary tumours which arise from the posterior spinal column and have traditionally been treated with intralesional resection. The purpose of this study was to review the treatment and local recurrence rates for symptomatic osteoid osteomas.

Methods: Utilizing the AOSpine Knowledge Forum Tumor multi-center ambispective database, surgically treated osteoid osteoma cases were evaluated. Descriptive statistics were summarized.

Results: A total of 84 osteoid osteoma patients (65 male, 19 female) received surgical treatment (mean age at surgery: 22 years (SD = 9) (range: 7-52 years)) between July 1990 and June 2012. Patients were followed for a mean period of 2.7 years (SD = 2.9). Most cases appeared in the mobile spine (81/84 (96%)); 63 cases (75%) were classifi ed as Enneking Stage 2 active benign tumours. All patients reported pain as a symptom.According to the surgeon’s postoperative assessment, 69 patients (82%) underwent intralesional resection, 12 (14%) had marginal surgery with complete excision of the nidus, and three (4%) had unknown surgical intervention. Only one patient received intralesional resection and radiation therapy. Six patients (7%) experienced a local recurrence, all of which occurred in the mobile spine and in the intralesional resection group. Five of the six patients experienced a local recurrence within two years postoperatively. Death was observed in one patient and the cause was unknown.

: ConclusionAccording to our fi ndings, most patients underwent an intralesional resection with all observed recurrences in this group. Although limited to 12 patients, marginal resection resulted in no recurrences.

09.20-09.2547. Survival of patients with Spinal Metastases from Nasopharyngeal Carcinoma Comparison of actual and predicted survival times

Presentation by Naresh Kumar, Jonathan Tan, Aye Sandar Zaw, Joel Louis Lim, Khin Lay Wai

University Hospital, Singapore

Background: The decision for operative treatment of patients with spinal metastases from various primary tumours is largely dependent on the predicted survival. Although Tokuhashi, Tomita, Bauer and Oswestry are popularly used for survival prognosis predictions, none of these systems have been evaluated in NPC. Objective: Our aim was to investigate the robustness of the four scoring systems in prediction of survival

for patients with NPC and to assist in establishing treatment for NPC patients with spinal metastases.

Methods: We retrospectively analysed the actual survival and compared with predicted survival according to the scoring systems of Tokuhashi, Tomita, Bauer and Oswestry for patients with Nasopharyngeal Carcinoma (NPC). Of a total of 814 histologically proven NPC patients who presented to our institution between 2007 and 2011, 87 patients with spinal metastases were studied. The predicted survival according to the four scoring systems was calculated and labelled as (A) scores. These scores were then re-scored by assigning NPC as a good prognostic tumour and labelled as (B) scores. The predicted survival of scores (A) and (B) were compared to actual survival. Univariate and multivariate Cox regression analyses were performed. The predictive values of each scoring system (A) and (B) were calculated using post estimation after Cox regression analyses. Results: The median overall survival for the whole cohort was 13 months (range: 1-120 months). In multivariate analysis, general condition, visceral metastases and vertebral metastases showed signifi cant eff ect on survival. The absolute score of all scoring systems were signifi cantly associated with actual survival, which extended to the diff erent prognostic subgroups of each scoring systems. Predictive value of survival by modifi ed Tokuhashi score was the highest among all four scoring systems.

Conclusion: All four scoring systems could be used to prognosticate NPC with a statistically signifi cant association with actual survival. The modifi ed Tokuhashi score is the best in doing so.

09.25-09.3048. Does surgical intervention within 48 hours in Cauda Equina Syndrome improve bladder outcome?

Presentation by Nisaharan Srikandarajah, Simon Clark, Martin Wilby

The Walton Centre, Liverpool

Introduction: Cauda Equina Syndrome (CES) can lead to loss of autonomic control including bladder dysfunction resulting in signifi cant disability. There is considerable debate regarding appropriate timing of surgery. A meta-analysis by Ahn UM et al, 2000 recommended within 48 hours of onset of symptoms. We analysed if operating within 48 hours of onset of autonomic symptoms made any diff erence to bladder function.

Methods: We conducted a retrospective cohort study of 200 patient case notes out of a complete dataset of 282 patients between 2000 and 2011 who underwent emergency decompressive surgery for CES at a single neurosurgical centre. Data collected includes clinical admission, operative details and autonomic outcome at initial follow up. Presentation was categorised into CES with retention (CESR) and incomplete CES (CESI) and duration of autonomic symptoms before surgical intervention, categorised as before or after 48hours.

Results: Two hundred patients presented with CES; 139 cases with CESI and 61 cases with CESR. Average initial follow up time was 96 days. For the 64 CESI operated before 48hours normal bladder function was seen at follow up in all patients except 10. However, for the 75 patients with CESI operated after 48hours, 42 had bladder dysfunction (Pearson Chi-Square p0.001). For the 61 CESR patients operating within 48 hours or after made no signifi cant diff erence to the autonomic outcome. All patients were operated within 48 hours of admission to the neurosurgical unit.

Friday, 4th April

Conclusions: Our data supports that decompressive surgery within 48 hours of onset of autonomic symptoms in CESI reduces bladder dysfunction at initial follow up but no diff erence in outcome was observed in CESR regarding timing of operation.

09.30-09.3549. Short term follow up the UNIPLATE device for use in anterior cervical discectomy and fusion

Presentation by Nick Rouholamin, Amit Patel, Ben Johnson, Vinay Jasani

University Hospital of North Staff ordshire

Purpose: The authors investigated the UNIPLATE device which was designed to be used in anterior cervical discectomy and fusion. It simplifi es the current technique in that only a single screw is used per vertebral body and can be placed into the same hole as the Casper distractor pins. The advantages are to minimise retraction on the midline structures, minimise surgical time and reduce chance of post-operative kyphosis.

Methods: Between 2006 and 2008 35 patients underwent ACDF using the UNIPLATE device by a single surgeon. 31 patients had single level surgery and four had 2 level surgery. Pre-operative and post-operative radiographs were compared in terms of overall disc height and angle of lordosis. Outcomes were determined by any post-operative kyphosis, symptomatic pseudarthrosis, and re-operation. RESULTS: 35 patients over a 2 year period. Mean follow up 24 months (6-37). Disc height was lost in no patients (0%). There was a mean increase in disc height of 1.1mm. 1 patient had loss of lordosis (2.8%) but no symptoms. Mean increase in lordosis 3.7 degrees. There were no symptomatic pseudarthroses and no re-operations.

Conclusions: The authors appreciate that not every surgeon advocates plating for single level anterior cervical discectomy and fusion. However for those surgeons that do advocate plating, we believe that the UNIPLATE off ers a simplifi ed technique, preserves vertebral bone, reduces retraction on midline structures, and provides good short term results.

09.35-09.4050. Long-term outcome following anterior cervical discectomy

Presentation by LR Sabir, SM Scullion, AJ Joannides, RJC Laing

Addenbrookes Hospital, Cambridge

Purpose: Anterior cervical discectomy (ACD) without cage or graft is rarely undertaken due to the perception that the absence of a spacer may lead to development of segmental kyphosis and loss of cervical lordosis, with resulting neck pain and impaired quality of life (QOL) in the long-term. We used a combination of disease specifi c and generic instruments to determine symptom severity and QOL following ACD without cage, graft or plate.

Methods: 204 patients undergoing ACD over a 12-year period were identifi ed. Visual Analogue Scales (VAS), Neck Disability Index (NDI), Myelopathy Disability Index (MDI), Short Form 36 (SF-36) and Hospital Anxiety and Depression Scale (HADS) were completed pre-operatively and long-term (>3 years) following ACD performed by a single surgeon. Questionnaire responses were recorded onto an electronic database to determine domain scores. Complete data was available for 74% (150/204) of patients. Minimum and median follow-up was 3.2 and 10.4 years respectively. Baseline and post-operative outcomes were

compared using paired t-test. Post-operative QOL outcomes were compared with age-adjusted control values using Welch’s t-test. Results: All disease-specifi c modalities showed improvement following surgery (VAS – neck pain, arm pain, arm tingling, hand numbness; NDI; MDI; all p<0.001). All SF-36 and HADS domains also improved post-operatively (p><0.001), with the exception of SF-36 general health (p=0.29). SF-36 generic components however remained signifi cantly lower than age-adjusted control values (p><0.001), with the exception of mental health (p=0.07).

Conclusions: ACD leads to sustained improvement in both cervical spine symptoms and overall QOL. However the recovery in QOL domains is incomplete when compared to age-matched controls.

09.40-09.4551. C2/3 Anterior Cervical Discectomy and Fusion – A Case Series

Presentation by Bethanabatla R, Jensen CD, Derham C, Timothy J, Thomson S, Towns G, Pal D

Leeds General Infi rmary, Leeds

Purpose: Anterior cervical discectomy and fusion (ACDF) surgery has been proven to be safe and eff ective treatment of disease below the third cervical vertebrae. However there is a paucity of literature investigating ACDF at the C2/3 level. The only published case series, a collection of 11 patients over 10 years, reported high complication rates (64%.)

Methods: We retrospectively reviewed a database of consecutive cervical spine surgeries performed at our institution to identify patients who underwent ACDF at the C2/3 level during a 5-year period. Demographic, clinical, operative and radiological data was evaluated.

Results: Eight patients (6 male: 2 female) with an average age of 57 years (22 to 78) were identifi ed as having had ACDF at C2/3 during the past 5 years. Indications were degenerative cervical myelopathy in 4 patients, trauma in 3 and infection in one. Mean operative time was 112 minutes, and there were no intraoperative complications reported. One patient, who had their surgery to decompress a high cervical epidural abscess, suff ered with postoperative systemic sepsis and died in the postoperative period. There were no other postoperative complications reported. C

Conclusions: We found ACDF surgery at C2/3 level to be safer in terms of complications, than had been previously reported. There is a need for further investigations into C2/3 ACDF surgery; however the low incidence of cervical disease at this level will mean that this will probably consist of further small case series.

09.45-09.5052. Incidence of False Positive Spinal Cord Monitoring Alerts in Surgery for Late Onset Scoliosis

Presentation by OM Stokes, E Bayley, R Burton, DA Rothenfl uh and H Mehdian

Queens Medical Centre, Nottingham

Introduction: Spinal cord monitoring alerts are decreases in amplitude of somatosensory evoked potentials (SSEPs) or motor evoked potentials (MEPs) and they direct the surgical team to the potential for neural injury. Alerts may be secondary to curve reduction, hypotension, or unknown causes. When surgical or

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anaesthetic manoeuvres fail to return the amplitudes to pre-alert levels, it is either associated with post-operative abnormal neurology (true positive), or normal neurology (false positive).

Methods: All cases of deformity correction for late onset scoliosis, between January 2003 and December 2012, had either dual- or mono-modality spinal cord monitoring to increase the safety of the procedure. The data from this consecutive series was prospectively collected identifying monitoring alerts, surgical or anaesthetic measures to address the alert and the post-operative neurological status of the patient.

Results: 512 procedures with a mean age of 13.5 years. 89 for neuromuscular scoliosis (NMS), 471 idiopathic (IS). 360 cases were monitored with SSEPs and MEPs. In NMS 83% were SSEPs only. 64 monitoring alerts occurred, 51 in cases with dual modality monitoring. Monitoring alerts occurred 48 times in IS (11%) and 16 times in NMS (18%). There were three true positive alerts (0.6%), all occurring in IS (0.7%) and all associated with surgical correction. There were 17 false positive alerts (27% of alerts), 15 occurring in IS. All the others corrected with surgical manoeuvres or correction of blood pressure. The false positive rate, when a spinal cord monitoring alert occurred, was 31% in IS versus 12.5% in NMS

09.50-09.5553. Post-operative outcome following lumbar discectomy: The value of pre-operative radicular pain proportion

Presentation by Hiren Divecha, Ben Fischer, Rajat Verma, Saeed Mohammad, Irfan Siddique

Salford Royal Hospital, Salford

Aim: To determine if the preoperative radicular pain portion prior to primary, single-level lumbar discectomy predicts postoperative functional outcome. Methods Patients were identifi ed from prospectively collected Spine TANGO data with Core Outcome Measures Index (COMI) recorded preoperatively and post-operatively at 3 and 12 months. The pre-operative radicular pain (%) was calculated from questions in the COMI score pertaining to leg and back pain. The median COMI score and radicular pain (%) were compared at all time points with paired Sign tests. Kendall’s tau correlation coeffi cient and linear regression analysis were used to investigate the relationship between pre-operative radicular pain (%) and COMI score at 12 months.

Results: Eighty-nine patients were identifi ed between August 2011 and December 2012. COMI scores improved signifi cantly post-operatively at 3 months (median change=3; range=-3.2 to 10; p<0.0001) and at 12 months (3; -1.5 to 9.6; p><0.0001). Radicular pain (%) reduced at 3 months (20; -39 to 100; ><0.0001) and at 12 months (6; -38 to 100; p=0.029). Kendall’s tau correlation coeffi cient between pre-operative radicular pain (%) and COMI score at 12 months was -0.281 (95% CI: -0.538 to -0.024; p=0.0268), indicating a modest negative relationship. The linear regression model showed a weak negative linear relationship (R2=0.155; p=0.0256).

Conclusions: Functional outcomes (COMI score) improve most at 3 months but continue to improve to 12 months following a primary, single-level lumbar discectomy. Importantly, this study shows that patients with higher pre-operative radicular pain (%), on average, have a lower COMI score at 12 months post-operative, indicating better functional outcome.

09.55-10.0054. Analysis of Bone Morphogenetic Protein-2 (rhBMP-2) in Revision Lumbar Spine Fusion for Pseudarthrosis: A Minimum One-Year Follow Up Study

Presentation by Rajiv Kaila, Venkatash Balaji, Lester Wilson

Royal National Orthopaedic Hospital, Stanmore

Introduction: Revision lumbar spinal fusion for pseudarthrosis is a growing problem. It is challenging as the fusion environment tends to be less than ideal. Iliac Crest Bone Graft (ICBG) has been the gold standard for revision surgery. There are concerns regarding donor site morbidity as well as the lack of suffi cient ICBG in the revision setting. The use of rhBMP-2 may overcome some of these problems. Benefi ts of rhBMP-2 in fusion rates have been previously shown in primary spinal fusion but there is a paucity of research that has evaluated its eff ectiveness in the revision setting.

Aim: The aim of this study was to analyse the outcomes of lumbar spine revision surgery for pseudarthrosis using rhBMP-2.

Method: Forty six consecutive patients who underwent revision surgery for psuedarthrosis with rhBMP-2 between January 2007 and December 2012 with a minimum one year follow-up were included in this retrospective review. The senior author performed all procedures. Demographic, surgical, and clinical data were collected from medical records. Fusion rate and complications were evaluated. Fusion was assessed on fi ne-cut CT scans.

Results: Our cohort had an average age of 53 years (range 28-71 years) at time of revision surgery and mean follow-up of 3 years (range, 1-6 years). Each patient had an average of two spinal levels treated (range 1-6). Overall fusion rate was 95.6% (44/46). There were two cases of non-union, however both patients declined further surgery as clinical outcome had improved signifi cantly. Complications included one cases of infection, and fi ve cases related to instrumentation. There were no BMP related complications.

Conclusion: This large cohort study shows that rhBMP-2 may be an appropriate alternative to ICBG in revision spinal fusion for pseudarthrosis. Further studies are needed to clarify its role.

10.00-10.0555. Modifi ed Hirabayashi Procedure (Open Door Laminoplasty) for the treatment of myelopathy secondary to ossifi cation of posterior longitudinal ligament – Sheffi eld experience

Presentation by Daniel Brown, Ankur Saxena, William Ripley, Dev Bhattacharyya

Royal Hallamshire Hospital, Sheffi eld

Introduction: Ossifi cation of the posterior longitudinal ligament (OPLL) results in narrowing of the spinal canal and resultant myelopathy due to spinal cord compression. The prevalence is highest in Japan (1.9%-4.3%) and is about 0.12% amongst the Caucasian population of North America. Only sporadic cases have been reported from Europe. Surgical decompression has been well described, from both anterior and posterior approaches. Hirabayashi et al. described the expansive open-door laminoplasty (ELAP) to increase the transverse dimensions of the spinal canal by elevating the laminae on one side, bending the outer cortices on the other side and suturing

the spinous process to the fascia. Our modifi cation to the procedure involved securing the elevated lamina to the lateral mass with custom made plates.

Method/Results: A retrospective review of case notes of all patients who underwent ELAP for OPLL at our institution was performed (n=4). The average age was 55 years. Pre-operative Nurick scores ranged from 1-4 (mean 2). All surgeries were performed on the cervical spine and the average number of levels decompressed was 4. No intraoperative or immediate postoperative complications were noted. All patients were followed up for at least three months. Post-operative imaging showed an almost 100% increase in the antero-posterior canal diameter.All four patients experienced signifi cant improvement in their myelopathic symptoms and Nurick scores.

Conclusion: ELAP is the preferred method in our practice as it is safer than anterior approaches with less risk of CSF leakage and achieves the similar goal of increasing the spinal canal diameter and preventing neurological deterioration in the setting of spinal cord compression. However posterior decompression could lead to reperfusion injury of the spinal cord or traction injury to nerve roots which possibly explains some common post-operative symptoms.

10.05-10.1056. Cervical kinematics after total disc replacement (TDR): fl exion-extension and lateral bending motion patterns

Presentation by Christian Mazel

Institut Mutualiste Montsouris, Paris, France

Background: Few studies investigate the nature of this preserved motion in TDR and there are no “in vivo” analyses of the biomechanical behaviour of cervical prostheses in both sagittal and AP planes.

Purpose: To evaluate sagittal alignment, motion in fl exion-extension, lateral bending after cervical TDR .Study Design: prospective multicenter observationalPatient Sample: 88 patients (39m/49w, mean 45) average FU 48 months. 1-level TDR

Outcome Measures: Radiographic: fl exion-extension (FE), lateral bending (LB) ranges of motion (ROM), mean centers of rotation (MCR), cervical and local lordosis

Clinical: pain VAS, function NDI, symptoms evolution (ODOM).

Methods: Analysis of biomechanical parameters and clinical data before surgery and at FU 3, 6, 12, 24, 36 or 48 months.Results: Cervical lordosis progressively increased from 45.4 ±11° before surgery to 51.4±12°at FU. Flexion-extension mobility at index level was preserved in 87.5% of cases (averaged 7.2 ±4° at 1 yr and 7.3 ±4° at FU). MCRs were abnormal in 37% of cases at FU vs. 56% before surgery. Adjacent levels kinematics demonstrates no signifi cant changes during follow-up. LB mobility increased from 5.4±3° before surgery to 7.2±4° at FU. No uncii impingement was noted, ROM was< 3° in 8 cases. MCRs location was centered on the upper vertebra in 50% of cases, scattered around this location in the others. Ranges of motion and MCRs locations were diff erent between fl exion-extension and lateral bending,. Clinical outcomes were satisfactory in 88 %. There was no correlation between clinical outcome and mobility.

Conclusion: Abnormal MCR locations (36%) suggest that prosthesis design may modify motion patterns at index level, which are diff erent in fl exion extension vs lateral bending. 7/11 patients with FE ROM <3°still presented a mobility in LB, showing that kinematics in both sagittal and frontal plane may be important in motion evaluation. Adjacent levels mobility was preserved at follow-up.

10.10-10.1557. Can the Weinstein-Boriani-Biagini (WBB) radiological classifi cation system be used to guide us in the management and decision making of metastatic cord compression (MSCC) and potential neurological recovery?

Presentation by Bhalla A, Ahmad S, Fawdington R, Gindar l, Balain B, Trivedi J, Jaff ray D

Robert Jones and Agnes Hunt Hospital, Oswestry

Purpose: Metastatic cord compression (MSCC) requires critical understanding, prompt diagnosis and treatment. Once diagnosed a plethora of variables are at play to determine prognosis. The purpose of this study was to investigate whether the Weinstein-Boriani-Biagini (WBB) system could be used to help guide treatment, and give an indication of potential for neurological recovery.

Methods: All patients with MSCC with neurological involvement during a 6-year period from Jan 2006 to Jan 2012 were included in the study. Patients who had medical notes and digital images available were divided into operated (n=40) and non-operated groups (n=26). The radiological classifi cation was assessed independently by an orthopaedic surgeon and a radiologist. Outcome measures included neurological improvement and complications. Correlation analysis was carried out between the groups.

Results: Patient dermographics such as age, gender, primary tumour types, disease levels and degree of compression on WBB were similar and comparable between the two groups. The degree of cord compression as per the WBB system was similar in those who improved after surgery (n=8) and those who did not (n=30). Of the two patients with worsening neurology, both had grade E involvement on the WBB system. There was no clear correlation between mortality rates, neurological recovery and the degree of compression on WBB (P=#.##).

Conclusion: The degree of cord compression according to the WBB system does not appear to correlate or act as a guide to neurological recovery; We suggest that the classifi cation is not useful to guide decision making in MSCC patients or predicting neurological recovery.

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10.15-10.2058. Defi nitive Correction Following Growing Rod Treatment for Early Onset Scoliosis

Presentation by Baxter G (Medical Student), Yasso S (Medical Student), Towriss C (Medical Student). James S (Consultant), Jones A (Consultant), Howes J (Consultant), Davies P (Consultant), Ahuja S (Consultant),

Spinal Unit, University Hospital of Wales

Aim: Analysis of fi nal outcomes of patients who have undergone defi nitive fusion following growing rod for management of Early Onset Scoliosis (EOS).

Method: All patients undergoing growing rod surgery for EOS at a single centre were evaluated of which 11 had defi nitive fusion. 8 had idiopathic scoliosis and 3 congenital. 10 patients had Paediatric Isola growing rod system and 1 had a VEPTR construct. The average follow up time was 8 years 5 months. Medical notes and radiographs were assessed. Results: Average Cobb angle was 69.3° (54-88°) prior to initial growing rod surgery, which reduced to 39.4° at fi nal follow up post fusion; a mean reduction in curvature of 43.1%. Mean T1-S1 spinal growth was 106.6mm (36-226mm). Average age at initial surgery was 7.5 years (3-10). Mean age at the time of surgical fusion was 13.75 years (11-16). The duration that growing rods were utilised was on average 6.3 years (3-10) per patient. The cohort underwent 10.8 surgeries each on average. All patients had fused apical segments. 2 patients had partial fusion of the apical segments hence the apical vertebra were instrumented to correct the spine. Of the remaining 9 patients; 1 had uninstrumented fusion, 1 had anterior and posterior osteotomy and correction, 1 had posterior osteotomies and correction, 6 had correction without instrumentation of the apical segment. Three patients experienced immediate complications following fusion; one patient had a temporary neurological defi cit and two patients experienced keloid scarring. A further 2 patients had long term complications; one patient required trimming of prominent metalwork. The other patient had a costoplasty for treatment of a prominent rib hump. Conclusion: All the patients had fused apical segments despite intra-muscular implantation of the growing rods or use of the VEPTR device. This aff ected the amount of correction possible with the defi nitive fusion and the complexity of the defi nitive fusion.

10.20-10.2559. Outcome following interbody fusion v/s posterolateral fusion for spondylolisthesis. is there a diff erence?

Presentation by Harinder Gakhar, Seyed Almaleki, Ganesh Prasad, Hatem Saleh, Rajendranath Bommireddy

Royal Derby Hospital, Derby

Background: Surgical treatment of low-grade spondylolisthesis has been a matter of debate. We present the results of a retrospective cohort that underwent either trans-foraminal lumbar interbody fusion (TLIF) or postero-lateral instrumented stabilization and fusion (PLF) for grade I/II degenerative or lytic spondylolisthesis.

Aim: To assess and compare overall patient satisfaction following trans-foraminal lumbar interbody fusion (TLIF) or postero-lateral instrumented stabilization and fusion (PLF) for grade I/II degenerative or lytic spondylolisthesis.

Methods: Between 2007 and 2012 we identifi ed 73 patients who had surgery for grade I or grade II spondylolisthesis. This was a retrospective case notes review of this group. Notes were made about demographics, age, gender, level and grade of spondylolisthesis, surgical procedure, length of follow up, complications and overall patient satisfaction (Back and leg pain).

Results: 45 patients underwent PLF and 28 had TLIF. In the TLIF group we had 13 females and 17 males. Average age was 53 years (28-78 years). In the PLF group we had 32 females and 13 males. Average age was 62 years (35-90 years). 3 cases had L3,4 level involvement, 40 had L4,5 and 30 had L5,S1 level aff ected. In all we had 60 grade I spondylolisthesis and 13 grade II spondylolisthesis.We had 3 wound infections one in TLIF and two in PLF group. All needed washouts and all settled with antibiotics. Overall 82% patients (23 of 28) were satisfi ed with the intervention in TLIF group. In PLF group overall 87% (39 of 45) patients were satisfi ed with the intervention. Reasons for dissatisfaction were residual back pain in 9 patients and residual leg pain in 2 patients.

Conclusions: Based on this review we can say that both TLIF and PLF provide similar satisfactory results in low-grade spondylolisthesis.

10.25-10.3060. Changing prophylactic antibiotics for posterior spinal surgery: Are we putting our patients at risk?

Presentation by Simon Craxford, Michael Gale, Masood Shafafy

Queens Medical Centre Nottingham

Purpose: In an attempt to reduce rates of Clostridium diffi cile associated diarrhoea (CDAD) our institution switched from Cefuroxime to a combination of Gentamicin (2mg/kg) and Flucloxacillin prophylaxis for spinal surgery. We sought to assess the impact of this change on our post-operative complication rates. Our primary study aim was to assess rates of acute kidney injury (AKI) between the diff erent antibiotic regimes. Secondary aims were to assess rates of CDAD and rates of surgical-site infection (SSI). Methods We carried out a retrospective cohort study of 180 patients who underwent spinal surgery in the prone position and received either Cefuroxime (group 1, n=90) or Gentamicin and Flucloxacillin (group 2, n=90). Rates of AKI, CDAD, SSI and return to theatre for infection within one year of original surgery (RTT) were compared in each group. AKI was defi ned as a post-operative increase in serum creatinine of 50% or more compared to preoperative values. SSI was defi ned as either wound discharge or erythema, or positive microbiology cultures. We also assessed known risk factors for infection and AKI including diabetes, age, site of surgery, blood loss, duration of surgery and ACE inhibitor use. Results There were 3 (3.3%) SSI and 1 (0.5%) RTT in group 1 compared to 16 (17.7%) SSI and 10 (11.1%) RTT in group 2, a statistically signifi cant diff erence. (p<0.01, OR 6.1), ><0.01, OR 11.1). There were no cases of CDAD in either group. There was no signifi cant diff erence in AKI rates (P = 0.053). There were no signifi cant diff erences in risk factors for infection or AKI in either group.

Conclusions: We conclude that Cefuroxime may be a more suitable prophylactic antibiotic than a combination of Gentamicin and Flucloxacillin in spinal surgery. Further prospective research involving larger patient numbers is needed to fi nd an optimal regime.

Special Poster Presentations

Non-Surgical

09.15-09.2031. Spinal Injection Therapy Performed By Physiotherapists- A 3 Year Evaluation of a New Service

Presentation by Patrick Hourigan, Helen Challinor, Andrew Clarke

RD+E Hospital, Exeter

Purpose: To report on the continuing development of a new service delivering spinal injections by non-medically trained personnel.

Methods: 2 years ago we reported upon the use of physiotherapists working in an extended role capacity, undertaking the diagnostic and therapeutic lumbar spinal injections at our institution.Over a 3 year period, 975 spinal injections have been performed by two of the Extended Scope of Practice (ESP) physiotherapists in our unit.

Results: The waiting time for spinal injection therapy has been reduced to a mean of 4 weeks from listing. This has remained constant. Urgent cases can be off ered treatment usually within 1 to two weeks. Waiting times in radiology for the same procedures remains 12-16 weeks.There have been no major complications in the 975 procedures performed.One of the ESPs has trained the other in spinal injection techniques to ensure continuity of delivery of service in his absence. He has trained some of our middle grade medical staff in spinal injection techniques also.Surgeons have been relieved of undertaking the majority of the spinal injections freeing up their time to pursue surgical treatments.

Conclusions: We have signifi cantly improved timely access to eff ective pain relieving treatments. ESPs provide a speedier service from assessment to treatment, and have equally successful outcomes with signifi cantly lower staffi ng costs. The majority of patients undergoing this treatment are of working age. By providing rapid access to treatment, we can minimise work absence bringing wider economic benefi ts both to the patients and general tax payers.

09.20-09.2532. Spinal injections for neck and lower back pain in the radiology department: An Out-patient model

Maire-Clare Killen, L Jagonase, M Chandran, V Pancho, P Lakshmanan

University Hospital North Tees

Background: Generally, diagnostic injections are a routine part of surgical procedures off ered by spinal surgeons. However, patients often have to wait for several hours before the procedure in a normal theatre setting and takes up valuable theatre time, increasing the cost for the healthcare provider.Aim: To evaluate the outcome and cost-eff ectiveness of spinal injections in a radiology department performed by a spinal surgeon, on an out-patient model assessing the effi ciency and satisfaction of a newly established, dedicated spinal injection service in the radiology department.

Methods: A prospective review of all patients undergoing fl uoroscopically guided spinal injections both cervical and lumbar spine on a dedicated injection list based in the radiology department over a six month period on an out-patient model. Observations and complications after the procedure were recorded. Patients were given a satisfaction questionnaire to complete following the procedure. The total time spent in the department by patients was also documented.

Results: A total of 261 consecutive patients underwent spinal injections over the course of a fi ve-month period. Patients were given appointment slots of 20 minutes each and they arrive just 10 minutes before the procedure. The median number of patients in a 6-hour injection list receiving treatment was 18.2 (range 16-20). No patient had signifi cant changes in their post procedure observations. 97% of patients completed a patient satisfaction questionnaire with 77% experiencing immediate reduction in their pain following injection. 6.8% of patients had subjective complications, including limb pain and transient weakness or paraesthesia. 100% of patients would recommend the service to a friend. One patient required admission overnight for observation. This model was found to be cost-eff ective as well.

Conclusion: Dedicated injection lists based on an out-patient model in the radiology department provide an effi cient and cost-eff ective service with high patient satisfaction levels.

09.25-09.3033. Impact of Elite Sports Participation on Active Cervical Spine Range of Motion in Men

Presentation by Bianca B Zietsman*, Ceri Ann Jones, Andrew Heusch and Peter W McCarthy

University of South Wales

Purpose: High achievement in sport associates with specialisation, intense training and performance. This can be the perfect environment for repetitive, cumulative relatively minor injury which can result in altered functional capacity [1]. Active cervical range of motion (ACROM) assessment is a non-invasive, simple and reliable way to study altered function in the cervical spine of elite sportsmen [2].

Methods: ACROM in fl exion/extension was recorded from elite athletes: (Professional Ice Hockey and Rugby Union, UK collegiate American football and international swimmers) using the method of Lark & McCarthy [1]. ACROM of players was compared to that from age and sex matched active (control) subjects.

ResultsTable 1 Flex Ext Tot Flex:extControl 54 ± 9 77 ± 3 131 ± 21 0.7 ± 0.1American Football 55 ± 8 66 ± 7 121 ± 15 0.8 ± 0.2Ice Hockey 52 ±13 68 ±15 119 ± 21 0.8 ± 0.3Rugby Forwards 46 ± 3* 43 ± 9* 89 ± 12* 1.1 ± 0.1*Swimmers 66 ± 10 69 ± 8 136 ± 12 1.1 ± 0.2*Table 1: ACROM (fl exion, extension and total) presented with proportion of fl exion compared to extension for each group: reported as degrees (mean ± 1 Standard deviation: *= p<0.05 compared to controls).

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Conclusions:Rugby union players have the lowest extension and fl exion with swimmers not appearing to be aff ected; however the ratio indicates a more central positioning in the neutral head position.

Keywords: Cervical spine, trauma, range of motion, degeneration, elite sports, diagnostic

References:1. Lark SD, McCarthy PW. Cervical range of motion and proprioception in rugby players versus non-rugby players. Journal of Sport Sciences 2007, 25: 887 – 89.2. Youdas JW, Garrett TR, Suman VJ, Bogard CL, Hallman HO, Carey JR. Normal Range of Motion of the Cervical Spine: An Initial Goniometric Study. Physical Therapy 1992, 72:770-780.

09.30-09.3534. Comparison of neurological improvements in Acute Traumatic Central Cord Syndrome following Surgical and Non-Surgical Interventions

Presentation by Naresh Kumar

University Hospital, Singapore

Background: Acute Traumatic Central Cord Syndrome (ATCCS) was fi rst described by Schneider in 1954. Since then there were strong advocates for treatment by non-operative approaches. Recent studies have shown encouraging neurological improvements in patients treated surgically. Our unit has treated patients with ATCCS both operatively and non-operatively.

Methods: We reviewed 59 patients who were treated at our hospital with a diagnosis of ATCCS from May 2005 to April 2011. Patients were identifi ed into 2 groups - operatively and non-operatively managed. Clinical indicators used for assessing neurological outcomes were the American Spinal Injury Association (ASIA) and motor score (AMS). These were obtained at the time of admission, in the immediate post-op period, and at the time from discharge from hospital. The surgical cohort was further stratifi ed into three subgroups based on the timing of surgical intervention after injury: surgery 24 hours till 1 week.

Results: The surgical cohort had 38 patients, in whom surgery was performed at a mean of 10.4 days (range, 0.6-150 days) following onset of injury. Half of them were operated on between 24 hours and 1 week. The surgical approaches used were: anterior approach (18 patients), posterior approach (19 patients), and combined anterior-posterior approach (1 patient). In the surgical cohort, the mean improvement in AMS was 13.6, with 11 patients improving at least one ASIA impairment scale grade from time of admission to discharge. Among the non-surgical cohort, the mean improvement in AMS was 9.6, with 3 patients improving at least one ASIA impairment scale grade.

Conclusion: The surgical cohort had a larger improvement in mean AMS as compared to non-surgical cohort. This study also points to potential benefi ts of early surgical intervention; the ones having surgery less than 24 hours had the best neurological recovery.

09.35-09.4035. Will I be taller? - Height gain following scoliosis surgery

Presentation by Z Alshameeri, N Din, S Charlton, D Conlan, J Crawford

Addenbrookes Hospital, Cambridge

Purpose: The curved spine in scoliosis is associated with shorter vertical height resulting in a short stature. This could potentially ameliorate patients’ dissatisfaction with their cosmetic appearance. Surgery signifi cantly improves the curvature and can also result in an immediate height gain. The aim of this project was to assess the importance of the immediate height gained by our patients (following surgery) and if they were satisfi ed with the amount of height they perceive to have gained.

Method: We initially reviewed the medical records for height measurements of our adolescent patients who underwent correction surgery for idiopathic scoliosis over a period of 18 months. Then we prospectively asked the same patients to complete a feedback questionnaire regarding the importance of the height they gained and whether they were satisfaction with it.

Results: A total of 42 patients were included. 39 (93%) had expected their height to change after surgery. A quarter (n=11; 26.1%) considered the additional height gain as important or very important and almost two thirds (n=27; 64.1%) thought their immediate height gain met or was higher than their expectations. The average perceived height gained was 3.9cm which was similar to the true (measured) average height gained of 3.4 cm; achieving a moderate correlation of r2==0.600 ( p=0.001). The average satisfaction score (on a visual analogue scale of 0-10) was 7.1 which correlated with the perceived height gained (r=0.56; p<0.001). There was also a signifi cant but weak negative correlation between the preoperative height and the amount of immediate height gained (r= -0.4; p= 0.037).

Conclusion: Good proportion of patients considered the immediate height gain as an important part of surgery. Therefore, patient’s expectations regarding height gain should be discussed before surgery in order to avoid dissatisfaction if the actual true height gain did not meet their expectations.

09.40-09.4536. Therapeutic ive nerve root blocks for symptomatic lumbar disc herniation: one year follow-up and cost analysis

Presentation by Ryan Wood, Henry Budd, David Cumming

Ipswich Hospital, Ipswich

Background: The role and timing of selective nerve root blocks (SNRBs) in the management of symptomatic lumbar disc herniation remains debatable. Both operative intervention and epidural steroid injection have been shown to be effi cacious in randomised control trials. In our unit, all symptomatic patients with positive MRI scans are treated initially with SNRB. If they remain symptomatic on follow-up, they will then be off ered discectomy.

Method: Retrospective analysis of all patients undergoing therapeutic SNRB for lumbar radiculopathy secondary to disc herniation. Data collected on rate of follow-up, time to follow-up,

rate of further operative procedure and time to operation. A cost analysis was performed to compare average procedural costs per patient for SNRB followed by discectomy if required versus discectomy off ered as a primary procedure.

Results: 106 patients were identifi ed over a fi ve months period with at least 3 months of radicular symptoms and one year of follow-up. 54% of patients did not require any follow-up and were discharged. 46% were followed-up either in person or by telephone. Of these a further 26 patients (25% of total) went on to discectomy with 4 patients undergoing further SNRBs and the remainder discharge. This equates to an average procedural cost of £1,572 per patient compared with £2,335 for patients off ered discectomy in the fi rst instance.

Conclusions: Therapeutic SNRBs are an eff ective, surgery-sparing, cost-eff ective procedure.

09.45-09.5037. Syringomyelia secondary to dorsal arachnoid webs

Presentation by Parag Sayal, Wisam Selbi, Ahilan Kailaya-Vasan, Arif Zafar, Thomas Carroll

Royal Hallamshire Hospital, Sheffi eld

BACKGROUND AND OBJECTIVE: In a certain group of patients with syringomyelia, even with the advent of sophisticated MRI, no associated abnormality or CSF block is easily identifi ed. This type of syringomyelia is often termed idiopathic. Current literature has very few reports of arachnoid webs which were identifi ed on myelography to be the causative factor. A reduction in the subarachnoid space compliance with resultant increase in pulse pressure and potentiation of an arterial pulsation driven perivascular fl ow could explain the associated syringes. We present our experience in the management of 2 cases of syringomyelia secondary to arachnoid webs CLINICAL

PRESENTATION: Both our patients presented with progressive neurological deterioration with MRI scans demonstrating Cervico-thoracic syrinx without Chiari malformation or low lying cord. There was no history of previous meningitis or trauma. Both patients underwent myelography which demonstrated

dorsal fl ow block implying Csf obstruction INTERVENTION: Both patients underwent thoracic laminectomy , After opening the dura, thickened / abnormal arachnoid tissue was found which was resected thus widely communicating the dorsal subarachnoid space. Postoperatively at 6 months, both patients had signifi cant symptomatic improvement with follow up MRI scans demonstrating signifi cant resolution of the

syrinx. CONCLUSION: In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. We believe that all patients with idiopathic symptomatic syringomyelia should have myelography to identify such arachnoid abnormalities which are often underdiagnosed. Subsequent surgery should be directed at the establishment of normal CSF fl ow by laminectomy and excision of the off ending arachnoid tissue.

09.50-09.5538. The impact of a One-Stop pre-assessment clinic in scoliosis surgery

Presentation by Z Alshameeri, N Din, S Charlton, D Conlan, J Crawford

Addenbrookes Hospital, Cambridge

Purpose: Scoliosis corrective surgery is a major procedure that requires extensive preoperative assessments and counselling. This often necessitates multiple appointments with diff erent specialists. Therefore, our department introduced a one-stop clinic in which the initial preoperative assessments are carried out in one day. This has been convenient for patients but we wanted to assess whether this had an impact on the overall length of the preoperative assessment period and the time-delay to surgery.

Method: We conducted a retrospective audit that included consecutive patients (children and adolescents) who had scoliosis correction surgery between January 2006 and 2008 (group 1; before the introduction of the one-stop clinic) and patients who had surgery during the year 2012 (group2; after the introduction of the one-stop clinic). We assessed the time-delay between the dates of the referral for the initial pre-operative assessments and the dates when these assessments were carried out (for group 1) or the date of the one-stop clinic (for group2). We also assessed and compared the delays to the dates of the MDT meetings and surgery for both groups.

Results: In total we had 32 consecutive patients in group one and 48 patients in group two. The preoperative assessment period decreased signifi cantly after the introduction of the one stop clinic ((p=0.02); from 21 weeks to 17 weeks. This has also resulted in a shorter time-delay to the MDT meeting; from 31 weeks to 25 weeks, however this was not statistical signifi cant (p=0.08). The total number of surgical procedures for scoliosis correction has signifi cantly increased since the introduction of the one-clinic and despite this, the time-delay to surgery remained almost the same.

Conclusion; The signifi cant reduction in the preoperative assessment period after the introduction of the one-stop clinic could potentially improve patients’ satisfaction and help in achieving waiting-time targets for surgery.

09.55-10.0039. The relationship between pelvic incidence and spinopelvic sagittal parameters in adolescent idiopathic scoliosis- a prospective cohort meta analysis

Presentation by Brett Rocos, John Hutchinson

Frenchay Hospital, Bristol

Purpose To ascertain if the widely used formulae and algorithms in clinical use predicting the relationship between pelvic incidence, lumbar lordosis and thoracic kyphosis were valid in this group of patients.

Method A review of the literature and a questionnaire of spinal surgeons revealed that the 2 most used formulae were ‘lumbar lordosis = pelvic incidence + 9°’ and ‘pelvic incidence + lumbar lordosis + thoracic kyphosis< 45°’ with a mean negative diff erence of 11.2° (95% CI ±4.5°). Results In the sample, mean pelvic incidence was 49.9° (95% CI ±1.6°), and mean lumbar

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lordosis 46.3° (95% CI ±1.4). The mean diff erence between these values was found to be 3.6° (95% CI ±1.5°). 26/81 (32%) patients had a sum of pelvic incidence + lumbar lordosis + thoracic kyphosis > 45° with a mean negative diff erence of 11.2° (95% CI ±4.5°).

Conclusion In pre operative planning and post operative review of patients with adolescent idiopathic scoliosis, these 2 formulae may have weak utility in both planning and understanding their sagittal balance.

10.00-10.0540. A Retrospective Standard Based Audit to Evaluate Time to Assessment and Subsequent Management of Patients Diagnosed with Cauda Equina Syndrome (CES)

Presentation by Joanne Roberts Denise Prescott Marcus deMatas Royal Liverpool and Broadgreen Hospital, Liverpool

Purpose The Society British Neurological Surgeons (2009) published standards of care for established and suspected CES that were based on expert opinion. If CES is confi rmed emergency referral to specialist care is required for immediate decompression, to prevent further neurological defi cit. The purpose of this study was to determine if the management of CES at RLBUHT complied with published standards of care. Methods A data collection “proforma” was devised, and microdiscectomy patients records were reviewed between January 2010 to October 2013. All patients diagnosed with CES undergoing surgical decompression were identifi ed. Data collected was time from admission to MRI and time to decompression if CES was confi rmed. Results 20 patients had radiologically confi rmed CES. 18 CESI &2 CESR Median time to MR scan 17 hr53 Range 1 hr40 – 30 hr43 (11 patients 5 had scan pre- admission, no admission time for 3 patients 1 is unknown) Median time to surgical procedure 30hr30. Range 4hr30 -89hr42 (17 patients as admission time was not noted for 3 patients) 1 patient was transferred to Local neurosurgical unit for surgery 19 patients recovered gross bladder control + continence. 1 patient required intermittent self-catheterization

Conclusion: In this audit 95% of patients had complete return to continence . Scan were performed on site and all assessment + surgery performed by a consultant spinal surgeon. The SBNS 2009 does not clarify timing of MR scanning/Surgical decompression. The literature is divided as to the optimal time for surgery. However it has been suggested this should occur within 48 hours (Gitelman et al 2008). A more detailed robust guidance is needed on timing of scan + surgical decompression for such a controversial subject.

10.05-10.1041. Missed diagnosis of Spondyloarthropathy

Presentation by Rohit Dhawan, V Pullicino, JM Trivedi

Northern General Hospital, Sheffi eld

Purpose Magnetic resonance imaging (MRI) scan is increasingly replacing plain radiographs as the initial and only investigation in patients with low back pain. However, the sacro-iliac (SI) joints are not routinely included in an MRI scan of the lumbar spine. This study highlights the danger of missing the diagnosis of spondyloarthropathy as a direct consequence of this change in imaging practice. Methods We retrospectively report on twenty-fi ve adults referred to our unit with lower back pain presumed to be non-infl ammatory in origin. All patients had had an MRI

scan of the lumbar spine as the primary investigation for their symptoms at the parent hospital. Review of the initial MRI scans from the parent institute revealed the presence of subtle infl ammatory changes that had been overlooked previously. Results Subsequent imaging of the SI joints (pelvic x-rays/CT scans) confi rmed sacro-iliitis consistent with infl ammatory arthropathy changes in all the patients. Conclusion The use of MRI scan as the only investigation in these patients with low back pain may have resulted in an error of diagnosis from failure to visualise the SI joints on these scans. We propose either a routine inclusion of SI joints in the MR sequences or acquisition of conventional radiographs of the SI joints for all patients presenting with lower back pain

10.10-10.1542. The infl uence of lumbar spine subtype on lumbar intervertebral disc degeneration in young and middle-aged adults

Presentation by PAG Torrie, G McKay, R Bryne, SJ Morris, IJ Harding

Frenchay Hospital Bristol

Purpose: To determine if young patients with diff erent lumbar spine subtypes (I-IV) have varying patterns of lumbar intervertebral disc degeneration (LDD)Method: Retrospective case series based on review of 608 consecutive patients. A standing lateral plain fi lm radiograph with temporal MRI scan and <50 years were the inclusion criteria. Measurement of the sacral slope, pelvic tilt, pelvic incidence, infl exion point, lumbar lordosis, lumbar spine subtype (Roussouly) and Pfi rrmann grade of LDD were obtained.A stratifi ed disc degeneration score (SDDS) was derived. The null-hypothesis was that lumbar spine subtype would not predict the level of LDD. The SDDS for the type I, II+IV spines were compared using a Chi-squared test. SDDS outlier levels were assessed for the type III spines. Signifi cance was accepted at P<0.05.

Results: 139 patients (91 female) aged between 13-49 years were included. There were 10(7.3%), 43(30.9%), 50(35.9%) and 36(25.9%) grade 1-4 lumbar spine subtypes respectively. Statistically signifi cant interclass diff erence in the values for sacral slope, pelvic incidence and lumbar lordosis but not pelvic tilt was observed (P<0.0001, P<0.0001, P<0.0001 and P=0.777 respectively). No statistically signifi cant interclass diff erence for age and gender was observed (P=0.43 and P=0.232 respectively). High-grade (Pfi rrmann IV +V) LDD increased distally towards the lower intervertebral lumbar levels, aff ecting 2.9%, 2.9%, 5%, 9.4%, 33.1%, and 54% of discs at each sequential lumbar level from T12/L1 - L5/S1 respectively. On analysis of the SDDS, lumbar spine subtype (I, II+IV) did not achieve statistical signifi cance (P=0.859, P=0.985 and P=0.384) respectively, when compared to the other 3 spine subtypes. L5/S1 was the only outlier in the type III spines.

Conclusions: Results of this study show that lumbar spine subtype does not appear to infl uence the aff ected level of LDD.

10.15-10.2043. ‘Call the Spinal Surgeons’ – an increasing trend in emergency referrals

Presentation by Timothy Hammett

Queens Medical Centre, Nottingham

Purpose - Spinal surgery is, by its specialised nature, a tertiary service. The provision of emergency spinal care falls under the remit of neurosurgeons or (less frequently) to dedicated spinal surgeons. We examined the perceived increasing trend in workload and referrals to our unit.Methods - All referrals made to neuro or spinal surgery at our tertiary centre since 2005 were prospectively recorded in a Microsoft Access database. We reviewed all referrals made between 01/01/2006 and 31/12/2012. We extracted all spinal referrals and subcategorised them to further analyse this trend. Our sub categories were Cauda Equina Syndrome, Myelopathy, Radicular pain, Infection, Trauma, and Tumour.Results - Out of 38,763 referrals made during the time period in question, 10,921 related to the spine. The number of spinal referrals during the period examined virtually quadrupled, increasing from 627 in 2006 to 2,412 in 2012. The increase was noted across all subcategories assessed.Conclusion - We have documented a rapid increase in the number of spinal referrals to our centre. There has not been an adjustment in our catchment area to explain this increase. It should be noted that this database only counts unique referrals to our service, but we feel this is an adequate proxy for the overall on call workload of the spinal team. Commissioning bodies and those responsible for setting up and maintaining the on call rotas for those centres providing emergency spinal care will need to acknowledge the increasing strain that this workload places on the staff and infrastructure and will need to ensure that adequate staffi ng is available to handle the ever growing number of referrals. We suspect that this refl ects the increasing tendency in modern medical practice to obtain advice from specialist centres and the increasing utilisation of diagnostic imaging.

10.20-10.2544. Physiological compensatory mechanisms in the proximal and distal axial skeleton in adolescent idiopathic scoliosis

Presentation by John Hutchinson, Brett Rocos

Frenchay Hospital, Bristol

Purpose - We present a concept based upon a review of 213 patients that patients with AIS accommodate unusual thoracic and lumbar sagittal profi les by adopting diff erent alignment of their pelvis and neck than the normal population. We propose that patients who have maximally used these compensatory mechanisms pre operatively will have little ‘physiological reserve’ and may be more prone to proximal junctional kyphosis. We would suggest that surgeons should assess pelvic tilt and cervical kyphosis in their pre-operative planning in this group of patients.

Methods - Data were collected regarding the preoperative radiological spino pelvic parameters of 81 patients with a diagnosis of adolescent idiopathic scoliosis and were analysed in conjunction with 132 cases available in recent literature. A meta-analysis of the combined data were carried out, and statistical analysis of each parameter carried out.

Results - This sample shows a pre-operative cervical kyphosis of 10.4° (95% CI ±1.7, and a pelvic tilt of 11.3 (95% CI ±0.9°) in patients with adolescent idiopathic scoliosis. Meta-analysis shows that the mean pelvic incidence in patients with adolescent idiopathic scoliosis to be 51.7° (95% confi dence interval 49.9- 53.5, mean pelvic incidence to be 49.9° (95% CI ±1.6°), and mean lumbar lordosis 46.3° (95% CI ±1.4). Cervical lordosis and pelvic tilt are signifi cantly diff erent to the normal population (p<0.005). Pelvic incidence is no diff erent from the normal population.

Conclusions - The results show that patients with idiopathic scoliosis do not have the same relationships between pelvic incidence and lumbar lordosis as the unaff ected population. This should be borne in mind when planning the correction of scoliosis and the restoration of the patient’s sagittal profi le. We believe that an understanding of preoperative sagittal balance may be essential in creating proper post-operative sagittal balance.

10.25-10.3045. Migrating intrathecal high velocity projectile

Presentation by Yuen Chan, Rafi d Al-Mahfoudh, Robin Pillay

Warrington Hospital

Purpose - The incidence of bullet injuries is on the rise and it is important to be aware of the management of bullet injuries. We present a case of a gun-shot injury to the spine with a migrating intrathecal bullet which presented no neurological defi cits and reviewed the literature surrounding management of intrathecal bullet injuries to the spine.

Methods - Case report and a literature review on management of intrathecal bullets

Results - A 27 year old male was admitted with a gunshot wound to the back. CT showed a fracture at L2 lamina. A bullet was located at the level of S1 vertebra. On examination, he was neurologically intact and was managed conservatively. He subsequently developed complete bilateral foot drops. A decision for operative treatment was made. Intra-operative imaging showed the bullet had migrated to the level of L4-L5. Post-operatively, the patient improved neurologically. There have only been a few previous reports of delayed neurological defi cit involving bullet migration. The reports have suggested good outcomes in patients who underwent operative intervention who present with no initial neurological defi cit who subsequently develops defi cits. The literature also recommended monitoring of patients managed conservatively for lead toxicity, which can present with a wide range of symptoms. Surgeons need to be aware of these symptoms and have a high suspicion for diagnosis.

Conclusions - With injuries involving intrathecal bullets, neurological defi cits on presentation are common. Spinal gunshot injuries can be managed conservatively if the patient is intact neurologically. Indications for removal of the bullet include evidence of lead toxicity, or copper bullets, CSF leak and neurological defi cit. Intrathecal bullets may not cause any neurological symptoms, however there is the potential to develop a neurological defi cit. Intervention for an evolving neurological defi cit seems to have favourable outcomes and surgery is likely to benefi t this subgroup of patients.

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Keynote Lecture 7

10.30-11.00Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic Type 1 changes): a double-blind randomized clinical controlled trial of effi cacy.

Presentation by Hanne B Albert, Joan S Sorensen

Background: Modic type 1 changes (bone edema) in the vertebrae is present in 6 % of the general population and in 35 %- 40% of the low back pain population. It is strongly associated with low back pain. The aim was to test the effi cacy of antibiotic treatment in patients with chronic low back pain (>6 months) and Modic Type 1 changes (bone edema).

Methods: The study was a double-blind RCT with 162 patients whose only known illness was chronic LBP of greater than 6 months duration occurring after a previous disc herniation and who also had bone edema demonstrated as Modic Type 1 changes in the vertebrae adjacent to the previous herniation. Patients were randomized to either 100 days of antibiotic treatment or placebo and were blindly evaluated at baseline; end of treatment and at 1-year follow-up. As Primary outcome measures were; disease-specifi c disability, lumbar pain. Secondary outcome leg pain, number of hours with pain last four weeks, global perceived health, EQ-5D thermometer, days with sick-leave, bothersomeness, constant pain.

Results: 144 of the 162 original patients were evaluated at 1 year follow-up. The two groups were similar at baseline. The antibiotic group improved highly statistically signifi cant on all outcome measures and improvement progressed from 100 days follow-up until 1-year follow-up. At baseline, 100 days follow-up, 1 year follow-up the Disease-specifi c disability RMDQ changed; antibiotic 15, 11, 5.7, placebo 15, 14, 14. Leg pain; antibiotics 5.3, 3.0, 1.4 placebo 4.0, 4.3, 4.3. Lumbar pain antibiotics 6.7, 5.0 3.7 placebo 6.3, 6.3, 6.3. For the outcome measures, where a clinically important eff ect size was defi ned, improvements exceeded the thresholds, and a trend towards a dose-response relationship with double dose antibiotics being more effi cacious.

Conclusions: The antibiotic protocol in this study was signifi cantly more eff ective for this group of patients, (CLBP associated with Modic I), than placebo in all the primary and secondary outcomes.

Posters Presentations

Inducing bone production in the degenerate intervertebral disc: an alternative to invasive fusion procedures?

Poster by Sarah Turner1,2, Birender Balain1, Stephen Eistenstein1, Sally Roberts1,2 1Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, SY10 7AG, UK

2ISTM, Keele University, Keele, Staff ordshire, ST5 5BG, UK

Purpose Recent research has focussed on the development of biological repair strategies for the degenerate intervertebral disc (IVD), but little attention has been given to developing a technique for inducing bone formation within the disc. Fusion procedures have been described as the ‘gold standard’ treatment for back pain associated with IVD degeneration, but these are invasive, painful and expensive. This study aimed to determine if cells in degenerate discs could be directed towards osteogenesis and so have the potential to drive a biological fusion in situ.

Methods Human IVD cells and bone marrow mesenchymal stem cells (MSCs) were isolated from disc herniation or back pain patients (IVD n=45, MSC n=4) and assessed for

stem cell markers by fl ow cytometry (positive for CD73, 90 and 105 and negative for CD14, 19, 31, 34, 45 and HLA-DR) and sections of disc tissue were immunohistochemically stained for progenitor cell markers. Cells were grown in monolayer for 21 days in ‘osteogenic’ medium (including 100nM dexamethasone, 10nm ß-glycerophosphate and 50μM L-ascorbic acid-2-phosphate) or with the addition of 1,25 dihydroxyvitamin D3 (0.1, 1 or 10nM). Calcifi cation was assessed by production of alkaline phosphatase.

Results The MSCs and IVD cells had typical stem cell markers, demonstrated both with fl ow cytometry and immunohistochemistry. In addition, the cultured IVD cells diff erentiated and produced mineralised matrix, when grown with either osteogenic medium or vitamin D3 (in a dose dependent manner), though not to the extent of the MSCs. Conclusion - This study indicates that a stem cell population is present within degenerate IVDs and is capable of diff erentiating along an osteogenic lineage. Further investigation is required to determine the optimal method of inducing bone formation by the degenerate IVD cells, but these results are encouraging for the development of a biological fusion technique in the future.

The correlation of facet tropism to the degeneration of the osteoporotic spinal unit and osteoporotic fractures

Poster by Thomas Pagonis, Panagiotis Givissis, Aristidis Kritis, Athanasios Pagonis, Anastasios Christodoulou

Orthopaedic Department, Karditsa, Greece

Purpose: The authors investigated the correlation of lumbar spine facet tropism (FT) to the degeneration of the spinal unit and osteoporotic fractures observed in an elderly population suff ering from osteoporosis.

Methods: By using our patient database we selected a cohort of 156 osteoporotic patients that were treated in our institution. All MRI’s included in the patient’s fi les were checked. Lumbar FT, (>7 degrees diff erence in symmetry between the orientations of the facet joints), was investigated in 780 functional spinal units (156 subjects).

Each segment at L1-2, L2-L3, L3-L4, L4-L5, and L5-S1 was assessed for degeneration and FT. Motion segments were classifi ed into two groups; one with FT and another with facet symmetry. We also accessed the presence of fractures in the same segments. For each group, demographics were compared.

Results: The incidence of osteoporotic fractures and degeneration were prevalent and statistically signifi cant in the FT group (p < 0.001).

Conclusion: Our study suggests that there is a correlation between lumbar FT, spinal motion degeneration and the prevalence of osteoporotic fractures. Further investigation is needed.

Key words: Facet Tropism, Spinal Motion Segment, Spinal Degeneration, Osteoporotic Spine

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Patients’ Afternoon - Public Meeting about the Spine

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The Nottingham Questionnaire; a New Tool to Assess Quality of Life in Neuromuscular Scoliosis

Poster by Hoda Mohajer-Bastami, Ann Marriott, Jim Hegarty, George Arealis, Bev Beeson, Nasir A Quraishi, Hossein Mehdian

Queens Medical Centre, Nottingham, UK.

Introduction: There is limited literature regarding the use of a dedicated questionnaire to assess the outcome of spinal deformity correction in patients with neuromuscular scoliosis. A multidisciplinary steering group were instrumental in designing an outcome questionnaire in our unit for use in patients with Cerebral Palsy (CP) and Duchenne Muscular Dystrophy (DMD).

Purpose: The purpose of this study was to assess the quality of life (QOL) in patients with neuromuscular scoliosis following spinal surgery using the newly devised Nottingham Questionnaire for Neuromuscular scoliosis (NQNMS) with particular reference to CP and DMD patients.

Methods: Our questionnaire was developed by the steering committee and granted ethical approval. The parameters assessed include sitting posture/balance, arm use, head control, breathing, chest infections, pain, eating, drinking, refl ux, mobility, transferring, washing, dressing, daily living, skin integrity before and after surgery. All answers were

given by the carers, parents or patients. Statistical analysis was performed using the SPSS 17 and statistical signifi cance was set at p=0.5

Results: Between 2001 and 2011, 20 patients with NMS were treated with posterior segmental screw fi xation - 10 with (CP) and 10 with (DMD). A total of 17/20 (85%) carers responded - 9/10 patients with CP and 8/10 with DMD. At fi nal follow-up (mean f/u 6.4 years (range 2-10), the parameters that improved in both groups were sitting posture (p = 0.01), eating and drinking and refl ux (p= 0.33) With mobility and transferring, and washing and dressing, there was no diff erence before or after the operation for both CP and DMD patients (p = 1.00) and the same happened with arm use (CP p=0.75, DMD p=0.81). Head control (p= 0.41) and breathing (DMD p=0.28, CP p=0.62), improved in DMD patients only whilst pain improved in CP patients (p = 0.17). Post-operatively, there was 1 patient with superfi cial wound infection.

Conclusion: Our questionnaire is simple and easy to use for the assessment of QOL in CP and DMD patients and had a good response rate (85%). Our study shows that spinal stabilization does improve QOL through improvements in sitting posture, breathing, refl ux, mobility and transfer, washing, dressing and arm use. Validation of the questionnaire in a larger group of patients is under way.

Wnt-Signalling in Intervertebral Discs - Another Player in Their Demise?

Poster by Sharon Owen, Helen McCarthy, Birender Balain, Sally Roberts

RJ&AH Orthopaedic Hospital Oswestry

Purpose: Wnt-signalling is an important sequence of molecular events involved not only in development, but it is increasingly being implicated in diseases, for example, the development of osteoarthritis within articular cartilage. However, its role in intervertebral disc degeneration is not well established. Nucleus pulposus (NP) cells have many similarities to chondrocytes and disc degeneration is often likened to osteoarthritis. This preliminary study has investigated the presence of key Wnt-signalling molecules in human and bovine NP cells and the development of cellular senescence.

Methods: Bovine NP and human disc cells (from surgical samples excised for lumbar disc herniation) were enzymatically isolated from IVD tissue and cultured in monolayer. They were treated with 0-80mM lithium chloride (LiCl), a known activator of the canonical Wnt

signalling pathway, for 0, 3, 8 and 24h. The cells were observed for (i) the activation of Wnt-signalling by the translocation of active (unphosphorylated) ß-catenin (demonstrated immunocytochemically) to the nucleus and (ii) the development of senescence, as demonstrated by senescence-associated ß-galactosidase (SA-ß-Gal) activity at pH 6, was detected.

Results: Bovine and human NP cells demonstrated nuclear translocation of ß-catenin in response to LiCl, both in a dose- and time-dependent manner. Interestingly human NP cells had higher levels of activated ß-catenin than the bovine cells at the start of the experiments but increased less in response to LiCl. This was mirrored by the SA-ß-Gal results in bovine NP cells, with more senescence at higher doses of LiCl.Conclusions - These results indicate that Wnt-signalling is present in intervertebral disc cells; it appears to be elevated in degenerate human disc cells and may play a role in the progression of the disease. This provides a potential area for therapeutic treatment, with the development of several novel agents aimed at controlling Wnt-signalling.

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Cerebral Abscess and seizure following Halo Pin Placement : The anatomy for pin placement

Poster by Rakesh Dhokia, Morgan Jones, Eugene Verzin, Jabir Nagaria

Belfast Spine Research Group

The anatomy for pin placement Purpose Halo vest immobilisation remains common place for upper cervical injuries. This case report and review of literature outlines a rare but serious complication of pin placement. Also consideration of pin placement is reviewed with the assistance of CT scan.

Method: A retrospective case report and review of the literature on cerebral abscess following halo pin penetration of the skull was performed using PubMed. A 38 year old gentleman sustained a Jeff erson fracture following a fall from a bridge. He was treated with immediate cervical immobilisation with a Halo vest. Standard 8lb/inch torque was applied to the pins and on initial placement and

sequential visits to the outpatient department.

Results: At 12 weeks following halo vest immobilisation he was placed into a cervical orthosis due to pin site infection with Staph. Aureus. 6 hours following removal his GCS had fallen and had generalised seizures. Ct scan had showed that the pin had penetrated the inner table and a localised cerebritis with collection requiring emergency neurosurgical decompression and drainage.

Conclusion: This poster is to outline the serious but rare complication of halo pin placement and local infection. We advocate corresponding review of the CT scan prior to pin placement. Pins should be placed in the thickest part of the bone in the standard safe zones. (Pictures to be included on the poster)

Complications of Growing Rods used for Early Onset Scoliosis

Poster by Baxter G (Medical Student), Yasso S (Medical Student), Towriss C(Medical Student), James S (Consultant), Jones A (Consultant), Davies P (Consultant), Howes J (Consultant), Ahuja S (Consultant)

University Hospital of Wales, Cardiff , UK.

Aims: To identify complications experienced by patients undergoing growing rods surgery for Early Onset Scoliosis (EOS) and investigate complication rates between diff erent growing rod implants.

Methods: All patients undergoing growing rod surgery for EOS at our centre were included in the study. Complications were defi ned as wound, implant, neurological, alignment,or general. Patients were separated into groups according to the implant used.

Results: 44 patients were included in the study. 27 had idiopathic scoliosis, 13 congenital, 3 syndromic and 1 neuromuscular. 25 patients had Paediatric Isola system, 7 had Paediatric Expedium, 4 had dual growing rods with

domino’s,8 had VEPTR device and 8 had MAGEC system (some individuals had multiple implants during treatment). Average follow up duration for each growing rod subgroup was; 5 years for Paediatric Isola and Paediatric Expedium, 4.25 years for dual growing rods with domino’s, 1.9 years for the MAGEC system and 5.8 years for the VEPTR construct. 76 (19%) complications resulting from 397 surgeries were identifi ed in total. These include 36 wound (47.4%), 24 implant (31.6%), 3 alignment (3.9%), 6 general (7.9%) and 7 neurological (9.2%) complications. Each patient experienced 1.75 complications on average. Of the 397 surgeries that the group underwent, 32 (8.1%) were unplanned surgeries due to complications. Complication rates for each implant subgroup were; 1.6 per patient for Paediatric Isola and Paediatric Expedium, 1.25 for dual growing rods with domino’s, 1.4 for VEPTR and 0.44 for the MAGEC system.

Discussion: Complications for EOS surgery are numerous and frequent. In our study the MAGEC system has the lowest complication rates, perhaps due to lesser number of surgical interventions required. The Paediatric Isola and Paediatric Expedium had the highest. However, diff erent constructs diff er in average follow up and cohort size and this should be taken into account.

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Improved outcome after spinal cord injury in transgenic mice with high levels of endogenous omega-3 polyunsaturated fatty

acids

Poster by Nabeel Virani, Siew-Na Lim, Simon C Dyall, Jing X Kang, Adina T Michael-Titus

Purpose: Studies have shown that omega-3 polyunsaturated fatty acids (PUFAs) can reverse the excitotoxicity caused by glutamate, decrease lipid peroxidation and modulate the infl ammation triggered by central nervous system (CNS) injury (King, et al., 2006). We hypothesised that raised omega-3 fatty acid tissue levels protect against spinal cord injury (SCI).

Methods: In this study we used fat-1 transgenic mice. These mice carry the Caenorhabditis elegans fat-1 gene, which encodes a desaturase that coverts omega-6 to omega-3 PUFA (Kang, et al., 2004). When fat-1 mice and wild type (WT) mice are maintained on a diet high in omega-6 PUFAs, fat-1 mice are capable of producing omega-3 PUFAs from the omega-6 type, resulting in an abundance of omega-3 fatty acids and a low omega-6/omega-3 ratio in their tissues. Thus we can produce two fatty acid profi les and study the impact of these changes on SCI. Results: We evaluated the

functional motor recovery following compression SCI in three groups of mice; fat-1 mice on an omega-6 diet, WT mice on an omega-6 diet, and WT mice on a normal diet, as a control baseline. Motor functional recovery was assessed using the Basso Mouse Scale for locomotor recovery (BMS). Fat-1 mice showed a signifi cant improvement in locomotor performance after SCI (P<0.05), which was correlated with a signifi cant protection of neurones and glia,and a decreased infl ammatory reaction.

Conclusion: The data supports the signifi cant neuroprotective potential of omega-3 fatty acids in central neurotrauma. With further research omega-3 fatty acids may translate into a prophylactic treatment for SCI. Bibliography Kang, J., Wang, J., Wu, L. & Kang, Z., 2004.Transgenic mice: fat-1 mice convert n-6 to n-3 fatty acids.. Nature, 427(6974), p. 504. King, V., Huang, W. & et al, 2006.Omega-3 fatty acids improve recovery, whereas omega-6 fatty acids worsen outcome, after spinal cord injury in the adult rat. J Neurosci, 26(17), pp. 4672-4680.

The Marfans Hypotension Eff ect

Poster by D. Lees, A. Bowey, B. Purushothaman, N. Griffi ths, J. Bedford, J. Andrews, D. Fender

Royal Victoria Infi rmary, Newcastle upon Tyne, UK

Hypotensive anesthesia is an essential component of spinal surgery, but must be balanced with the need for organ perfusion. Extreme hypotension can result in cord hypoxia and neurological injury despite excellent surgical technique and vigilant intraoperative cord monitoring. We present an audit of signifi cant hypotensive episodes and sympathomimetic requirement in adolescents with Marfan’s syndrome undergoing posterior scoliosis correction. Three cases of genetically confi rmed Marfans Syndrome were undertaken between 2011 and 2013. All 3 cases demonstrated episodes of signifi cant hypotension requiring a1-adrenergic receptor agonist administration. Pre-operatively ECG, echocardiogram and average pre-operative systolic blood were normal (average 112.7mmHg range 110-118mmHg). The fi rst hypotensive crisis (systolic average 42.7mmHg, range 42-46mmHg) presented at an average of 51 minutes post induction (range 45-55minutes), corresponding to prone positioning, and the second crisis

(average systolic BP 41 mmHg, range 39-42mmHg) at an average of 216 minutes (range 198-240 minutes). An average of 1.67mg (range 1.5-1.75mg) Metaraminol and 7mg of Ephidrine (range 6-9mg) was required to return the systolic pressure to a more acceptable level. In order to establish the signifi cance of these events, 3 matched cases (age, height, weight and surgery undertaken) were identifi ed and their anesthetic charts audited. In the idiopathic cases, there were no hypotensive crises (average systolic BP 60mmHg, range 58-62mmHg) and no need for vasopressors. Average blood loss was similar (453mls Marfans versus 503mls for idiopathic). Prior to surgery the characteristic long, narrow chest shape of Marfans Syndrome was noted and we suggest that the prone position places signifi cant anteriorposterior stresses on the hyperelastic chest, thus reducing the cardiac output secondary to reduced thoracic volume. We therefore recommend that the team remains vigilant for the long, thin chest characteristic of Marfans and should be prepared to convert the patient to the supine position at short notice if the hypotensive episode cannot be promptly resolved.

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Trans-oral approach for the management of a C2 Neuroblastoma

Poster by KMI Salem, J Visser, NA Quraishi

Queen’s Medical Centre Nottingham

We present a clinical case of an 8 year old boy presenting with a relapse of a right adrenal stage 4 neuroblastoma with a metastatic deposit in C2 with an anterior tumour mass pressing on the spinal cord resulting in gradually increasing pain in the base of skull but without gross neurological defi cit. We aim to present his investigation fi ndings, and discuss the surgical approach used in his management (an initial posterior stabilization form occiput to C5 with a posterior decompression form C1 to C3 followed by a trans-oral approach to resect the main bulk of the tumour anteriorly). This is the fi rst report of the use of a trans-oral approach to address a neuroblastoma lesion in the axial spine. This approach was used eff ectively to achieve local tumour clearance confi rmed at one year follow-up. Pertinent information to the spinal surgeon on neuroblastoma and the use of the trans-oral approach to the axial spine are discussed.

Severe cervical kyphosis in NF-1: Management and surgical treatment – case report

Poster by Jose Sousa, Paul Davies, Mohamed Ahmed, Saqib Masud

Spinal Unit, University Hospital of Wales

Purpose: To report a rare case of severe cervical kyphosis in a patient with NF-1.

Methods: 16-year-old boy with previously diagnosed NF1. Presented with cervical mechanical pain, functional disability and severe cervical deformity with secondary upper thoracic lordosis. No neurological symptoms were present. Radiographic fi ndings showed a 102-degree cervical kyphotic deformity and a varied degree of dystrophic vertebral changes (C3-T1). The patient was put on halo-gravity traction for 6 weeks followed by surgical correction through a combined posterior and anterior approach.

Results: 81-degree kyphosis correction was achieved after initial halo traction. The patient was kept in halo-gravity traction after posterior instrumentation and fusion from C4-T4. Correction of main kyphotic deformity was achieved, but due

to proximal end anterior instability, revision with extension of instrumented fusion from C2 to T6 was performed. At a second stage, anterior 8 level discectomy from C2-C3 to T2-T3 was done, fi bular graft was placed in the lower 5 levels and fi xed with anterior plating, in the upper 3 levels the gaps were fi lled with bone graft substitute. A 10,5-degree kyphosis correction was achieved. The patient was put on a Halo jacket for 3 months. In the immediate post-op left upper limb numbness and weakness was identifi ed, which subsided after 4 months. At 9 months follow-up, there was signifi cant improvement of cervical functional disability and mechanical pain, and bone fusion and preservation of the kyphotic correction had been achieved.

Conclusions: Severe cervical kyphosis in patients with NF-1 encloses a risk of further curve progression and neurologic disability. Early surgical intervention in this patients allows a better chance of correction and stabilization, reducing the risks of ensuing neurologic damage. The combined use of pre-operative halo traction, anterior and posterior approach and postoperative halo jacket concur to correct the deformity, maintain the correction and achieve bone fusion.

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Major trauma patients with spinal fractures: a 2year prospective study

Poster by M Prime, Z Safarfashandi, C Kirk, A Tennant, Y Lok, M Akmal.

Wexham Park Hospital, Slough

Purpose: Traumatic injury is the leading cause of death in children and adults <44yo. Approximately, 10% of patients admitted with traumatic injuries have spinal injuries (Hasler, 2011). The creation of Major Trauma Centre’s has resulted in the concentration of patients with spinal trauma. The purpose of this study was to analyze the TARN (Trauma Audit & Research Network) data for patients with spinal fractures admitted as major trauma.

Methods: A prospective database of all patients admitted as major trauma with spinal fractures between 01/01/2011 and 31/12/12 was analyzed. Results: Total 67 patients admitted as major trauma with spinal fracture (mean age 48.8yo, 73% male, mean length stay 18 days). Incident mechanism: 98.5%

blunt trauma (48.5% Fall’s >2m; 23.5% RTA’s; 22.0% Fall’s <2m). Injury intent: 81% non-intentional vs. 10.3% Intentional. Other factors: 72.0% none; 16.2% alcohol/drugs; 11.8% psychiatric (86% psychiatric patients committed act of self-harm). ISS (injury severity score) mean 16.6 (male 17.6; female 13.9). Mean ISS incident mechanism (RTA=19.8; Fall >2m=16.7; Fall<2m= 12.8). Mean ISS injury intent (non-intentional= 16.6; self-harm= 19.7). Mean ISS for additional injury factors (psychiatric=18.8; none=17.1; alcohol or drugs=12.0).

Conclusion: Major trauma patients with spinal fractures are predominantly male. The mechanism of injury is blunt trauma. There is a strong association between deliberate self-harm and psychiatric illness. Mean ISS is higher for males. Patients involved in RTA’s have the highest ISS for injury mechanism. Patients who commit acts of self-harm or have psychiatric disturbance at admission have a higher mean ISS.

Tacit knowledge in spine surgery: a systematic review and its relevance in joint consultant operating

Presentation by Morgan Jones, Rakesh Dhokia, Greg McLorinan, N Darwish, N Eames, E Verzin,

Royal Victoria Hospital, Belfast

Keywords: Tacit Knowledge, Surgery, Evidence Based Surgery, Learning, Education Introduction: The role of joint consultant operating and its potential benefi ts is of increasing interest within spinal surgery. Tacit Knowledge (TK) exchange is a signifi cant component of this dynamic.

Objectives: The concept of TK has enjoyed widespread success within the social sciences. Its relevance in surgical practice is poorly described. A literature review to evaluate existing evidence about TK and its use in surgical practice was performed. Methods: A systematic review of the MEDLINE and PsychINFO databases was performed using the following keywords: Tacit: knowledge: Surgery: Surgeon: Health professional: Apprenticeship: Personal Knowledge: Tacit Knowing: Tacit knowledge: Professionalism: Evidence Based Medicine: Results: The original search identifi ed more than 900 papers, commentaries and reviews of the literature.

To address the research question, all papers not describing primary research examining the process and outcome of tacit knowledge in some aspect of surgical practice were excluded. Only papers investigating clearly defi ned research questions were included. Only papers where the primary research question with application of an appropriate methodology were included. This resulted in identifi cation of 10 studies answering the primary research question and a further 44 papers answering secondary research questions.

Conclusions: The review highlighted that TK in surgical practice remains poorly defi ned. The literature recognises that TK plays a signifi cant role at individual and team levels which have relevance to surgical practice. The critical role of TK in expert professional practice and acquisition of surgical skill is described. The time dependent and observational nature of TK acquisition presents challenges in terms of assessment, teaching and explicit knowledge acquisition, but off ers potential opportunities within the framework of joint consultant operating. Finally, the need for greater recognition as well as exploration of the full role of TK in surgery aimed at better informing professional practice is argued for.

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The role of the pelvic parameters and the lumbar spine subtype in the aetiology of degenerative scoliosis

Presentation by PAG Torrie, R Purcell, SJ Morris, IJ Harding, P Dolan, MA Adams, IW Nelson, MJ Hutchinson

Frenchay Hospital, Bristol

Purpose: To determine if patients with coronal plane deformity in the lumbar spine have specifi c pelvic parameters or lumbar spine subtype compared to controls.

Method: Retrospective case/control study based on review of 250 patients aged over 40 years who had standing plain fi lm lumbar radiographs. Measurements of lumbar coronal plane angle (LCPA), lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence were obtained. “Cases” with degenerative scoliosis (n=125) were defi ned as patients with a lumbar coronal plane angle (LCPA) of >10°. Lumbar spine subtype (LSS) was categorized (1-4) using the Roussouly classifi cation. Sacral slope, pelvic tilt and pelvic incidence were compared using an unpaired T-test, lumbar lordosis was compared with a Mann

Whitney-U test. The eff ect of LSS on LCPA was compared using Kruskal-Wallis test in subgroups. Predictors of (LCPA) were identifi ed using stepwise multiple regression. Signifi cance was accepted at P<0.05.

Results: The prevalence of type I-IV lumbar spine subtypes in the case group were 12.8%, 20.8%, 30.4% and 36% respectively and in the control group were 10.4%, 38.3% and 28% and 23.3% respectively. A signifi cant diff erence for lumbar lordosis and pelvic tilt between groups was observed (P=0.0116 and P=0.0017 respectively), but no signifi cant diff erence for sacral slope and pelvic incidence (P=0.152 and P=0.0594 respectively). No signifi cant diff erence between groups for LSS in either case or control groups was observed (P=0.959 and 0.960 respectively). No signifi cant predictors of LCPA were determined; LSS (P=0.969), pelvic incidence (P=0.740), sacral slope (P=0.203) pelvic tilt (P=0.167) and lumbar lordosis (P=0.088).

Discussion: Results show that neither the LSS nor pelvic parameters appear to have a signifi cant infl uence on determining the LCPA in the degenerative lumbar spine.

Spinopelvic parameters in adolescent idiopathic scoliosis

Presentation by Brett Rocos, John Hutchinson

Frenchay Hospital, Bristol

Purpose: There is controversy in the literature regarding pelvic incidence in patients with adolescent idiopathic scoliosis. We aim to ascertain if pelvic incidence is diff erent in patients with adolescent idiopathic scoliosis is diff erent to the normal population. If this is the case, planning and predicting the eff ect of post-operative sagittal balance in this group of patients may require a diff erent set of algorithms than the normal population.

Method: Data were collected regarding the preoperative radiological spino pelvic parameters of 81 patients with a diagnosis of adolescent idiopathic scoliosis and were analysed in conjunction with 132 cases available in recent literature. A meta-analysis of the combined data was carried out, and the mean value of pelvic incidence compared with the asymptomatic population using an unpaired two tailed t test. By combining data, this constitutes the largest series

examining this characteristic in these patients to date.

Results: Meta-analysis shows that the mean pelvic incidence in patients with adolescent idiopathic scoliosis to be 51.7° (95% confi dence interval 49.9- 53.5). A two- tailed t test shows that the pelvic incidence is not diff erent in those patients with adolescent idiopathic scoliosis when compared to the normal population, although there is a greater incidence of extreme high and low pelvic incidence in scoliotic patients. Conclusion Pelvic parameters in this group of patients are not signifi cantly diff erent than the normal population. We feel that this must be taken into account in pre-operative planning and post-operative review of this group of patients.

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Posterior Only Pedicle Screw Construct For Correction Of Severe Neuromuscular Scoliosis Without Sacro-pelvic Fixation

Presentation by Devi Prakash Tokala, John Howse

University Hospital of Wales, Cardiff

Posterior Only Pedicle Screw Construct For Correction Of Severe Neuromuscular Scoliosis Without Sacro-Pelvic Fixation

Purpose: To evaluate clinical and radiographic outcome following posterior only pedicle screw fi xation of severe neuromuscular scoliosis (> 90°) and to determine if this approach can help us to avoid sacro-pelvic fi xation and anterior release surgery.

Methods: This is a retrospective study of seven Neuromuscular patients with severe scoliosis (>90°), operated between March 2010 & February 2013. The Mean age was 12.7 years (range 8-16). All patients underwent scoliosis correction with posterior only pedicle screw constructs with multiple posterior chevron

osteotomies, without sacro-pelvic fi xation. Radiographic analysis was carried out on the pre-operative and immediate post-operative PA radiographs. Results: Preoperative mean Cobb angle of 112.2° (range 90 – 131) was corrected to 47.8° (range 35 - 66) postoperatively achieving correction rate of 57.3%. The mean preoperative apical vertebral translation of 93.5mm (range 46 – 135) was corrected to 45.7mm (range 28 – 67) and mean preoperative pelvic tilt of 26° (range 5-44) was corrected to 13.2° (range 3 – 30) postoperatively. The mean operation time was 325.7 minutes. There were no intraoperative or postoperative complications. Subjective outcome was good in all patients.

Conclusions: Posterior-only approach with the use of an all-pedicle screw construct achieves satisfactory correction of the curve in neuromuscular patients with severe scoliosis, avoiding the need for sacropelvic fi xation and anterior release surgery.

Keywords: Neuromuscular scoliosis; severe rigid scoliosis; posterior only pedicle screw constructs.

A review of Red Flag GP Referrals to the Orthopaedic Spinal Service in Northern Ireland

Presentation by Thomson. S, Eames. N, McLorinan. G, Verzin. E, Hamilton. A

Musgrave Park Hospital, Belfast

Introduction: Traditionally red fl ag referral were made for patients with suspected malignancy, in the spinal service this is often expanded to include cauda equina syndrome. Patients who present to their GP with any red fl ag symptoms should be referred to the orthopaedic service for investigation. These symptoms include weight loss, back pain in teenagers/ children, deformity, reduced perianal sensation & incontinence, night pain and new deformity. These symptoms indicate serious spinal pathology requiring urgent intervention.

Aims: We aimed to determine the number of red fl ag referrals made to our orthopaedic spinal service and then evaluate how many of these were “true” red fl ags

Methods: A retrospective review of all red fl ag referrals to the orthopaedic spinal service in Musgrave Park Hospital was performed over a 4 month period. The outcomes of these referrals subsequent to MRI scanning were documented.

Results: There were 25 red fl ag referrals to spinal service Musgrave Park Hospital between 1st Jan and 30 April 2013. Of these cases 5 were “true” red fl ags with a new diagnosis of metastatic disease or possible primary tumour. There were no cauda equina syndromes diagnosed. Others all downgraded to urgent or routine review after either an MRI scan or outpatient review. 1 red fl ag was a second referral after previous red fl ag referral had been downgraded to routine – still remains routine as nothing has changed.

Conclusion: The term red fl ag is being used inappropriately in many cases. Red fl ag patients take priority and inappropriate use of this may delay other urgent cases which in turn impacts on patient care.

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Out of Hours Acute Cauda Equina Syndrome: Imaging and Outcomes

Presentation by Connolly. M, Thomson. S, Darwish. N, Eames. N, Verzin. E, McLorinan. G

Royal Victoria Hospital Hospital, Belfast

Introduction : Cauda equina syndrome is a relatively uncommon spinal emergency which requires prompt surgical intervention. The numbers of suspected cauda equina syndromes being referred to our unit appeared to be increasing when compared to the number of confi rmed cases.

Method: Retrospective review of 41 emergency out of hours (after 5pm) admissions to the spinal service in the Royal Victoria Hospital, Belfast between 1st July 2011 and 31st Dec 2011 with suspected cauda equina syndrome was performed. These patients were clinically assessed for cauda equina syndrome and appropriate imaging was undertaken.24hour MRI scanning is not available in our unit and our patients are scanned on the next available imaging list.

Results: The majority of patients received MRI scanning within working hours (usually the morning after admission). 2 patients received out of hours CT myelograms and a further 2 had CT performed during working hours.56% had disc pathology as the main cause for their symptoms but only 22% of the disc pathology cases radiologically confi rmed cauda equina compression. Of those with disc pathology 40% went on to have discectomy performed during their inpatient stay, all cases of confi rmed cauda equina syndrome were operated on the day of their scan.17% had normal imaging and 27% had other non-disc pathology.

Conclusion: Referrals for possible cauda equina syndrome are a common occurrence out of hours to our department. The majority of these do not have cauda equina compression requiring emergency intervention.

Pelvic tilt and cervical lordosis in adolescent idiopathic scoliosis

Presentation by Brett Rocos, John Hutchinson

Frenchay Hospital, Bristol

Purpose: To ascertain if the position of the pelvis and neck in normal standing x-rays in this group of patients was diff erent than that of the normal population and to understand how patients with adolescent idiopathic scoliosis accommodate their typical thoracic hypokyphosis, we looked to see if the proximal and distal axial skeleton was held in a signifi cantly diff erent position in patients with adolescent idiopathic scoliosis when compared to the normal population.

Method: Data were collected regarding the preoperative radiological spino pelvic and cervical parameters of 81 patients with a diagnosis of adolescent idiopathic scoliosis and were analysed and compared to published normal values using an unpaired two tailed t test. Results Normal cervical kyphosis

has been measured at approximately -41° from the occiput to C7, and +9.4 in the subaxial spine. Our sample shows a pre-operative cervical kyphosis of 10.4° (95% CI ±1.7°). Normal pelvic tilt has been shown to be 12.1° (SD = 7°). Our sample shows a tilt of 11.0 (95% CI ±0.9°).

Conclusions: Patients with adolescent idiopathic scoliosis appear to adapt and adopt very diff erent alignments of their pelvic and neck. We do not know if this is a physiological compensatory mechanism or pathological.

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Does intra-operative neurophysiological monitoring make surgery for spinal dural arterio-venous fi stulae safer?

Presentation by Ankur Saxena, Marcel Ivanov, Matthias Radatz, Dev Bhattacharyya, D Ganesh Rao

Royal Hallamshire Hospital, Sheffi eld

Background: Spinal AV-Dural fi stula (sAVDF) is an abnormal connection between a radicular artery and vein within the dural root sleeve leading to venous congestion and eventual ischaemia of spinal cord. Radiological embolisation of nidus and surgical disconnection of fi stula are two treatment modalities used to treat this disorder. No prognostic factors have been reliably established. Surgery subjects patients to potential complications therefore intra-operative neurophysiological monitoring (IONM) is used in our institution as an additional tool to ensure safer surgery. Method: Since March 2009, 11 patients with sAVDF underwent surgery with IONM. All patients had monitoring of somatosensory evoked potentials (SSEPs). Motor evoked potentials (MEPs) were missing in the fi rst three due to unavailability of equipment. Pre-operative baseline clinical and neurophysiological assessments were performed.

Results: Three patients had previous embolisations but their fi stulae had recanalised. Three patients had failed attempts at embolisation. One patient had absent SSEPs and MEPs due to spinal cord damage prior to surgery. He did not have any return of potentials post-operatively. Eight patients had the feeder vessel temporarily clipped for 10 minutes and two for 12 and 15 minutes respectively due to multiple clips being applied sequentially to multiple feeding vessels. No change in evoked potentials was noted in any case and the fi stulae were disconnected successfully without any intra or post-operative complications. The median follow-up was 6 months. All patients had a good outcome.

Discussion: There is insuffi cient information available on the use of IONM during surgery for disconnection of sAVDF. We discuss the rationale behind development of the protocols in our department where the feeder vessel is temporarily clipped for 10 minutes under continuous IONM and the decision to disconnect is made when no change in evoked potentials is noted. Such monitoring has made surgery safer and helps improve patient outcomes as per our experience.

Odontoid Process Fractures: The Role of the Ligaments in Maintaining Stability. A Biomechanical, Cadaveric Study

Presentation by Oliver Boughton, Matthew Szarko, Jason Bernard

St Georges Hospital, London

Aims: We wished to investigate the role of the cervical ligaments in maintaining atlanto-axial stability after Anderson and Alonzo type II fractures of the odontoid process.

Methods: We dissected 9 fresh frozen cadaveric cervical spines and prepared the C1 and C2 vertebrae for biomechanical analysis on block with careful preservation of the atlanto-axial ligaments. The odontoid process was cut to create an Anderson and D’Alonzo type II fracture. These C1 and C2 blocks were then mounted and biomechanical analysis was performed to test the stability of the C1-C2 complex with successive division of the atlanto-axial ligaments. Biomechanical analysis of stiff ness, expressed as Young’s modulus, was performed under right rotation, left rotation and anterior displacement.

Results: In right rotation, in the undissected specimen, the mean Young’s modulus was 2.6 x 10-5 MPa (megapascals). When the structures were divided the Young’s modulus reduced by the following percentages: odontoid process 55.0 ± 5.9%, joint capsule 18.3 ± 2.9%, ligamentum fl avum 9.2 ± 1.6% (total when all three divided: 82% decrease). In left rotation the relative contributions of the structures to the total stiff ness were: odontoid process 39.0 ± 10%, joint capsule 15.6 ± 1.1%, ligamentum fl avum 21 ± 0.5%. In anterior displacement the relative contributions of the structures to the total stiff ness were: odontoid process 46.3 ± 4.6%, joint capsule 10.1 ± 0.8%, ligamentum fl avum 9.2 + 0.2%.

Discussion: We have found that the odontoid process itself may account for up to 50% of the stiff ness of the C1-C2 complex and that the joint capsule and ligamentum fl avum may account for 20-30% of the stiff ness. We propose MRI imaging of the soft tissues should be performed in the acute setting of an odontoid process fracture with less than 5mm of displacement to help determine whether the fracture should be conservatively or operatively managed.

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Blood Loss in Spine Tumour Surgery - How Much Can the Surgeon Expect?

Presentation by Naresh Kumar, Yongsheng Chen, Deepti Nayak, Raymond Goy

National University Hospital, Singapore

Background: Patients undergoing surgery for spinal metastasis are more susceptible to the complications of intraoperative blood loss and associated transfusion. Presently, there is no consensus regarding the typical volume of blood lost during spine tumour surgeries. An accurate estimation of the potential volume of blood lost during surgery would thus facilitate appropriate pre-operative planning for blood transfusion.

Methods: A systematic review of the English literature was conducted using computer searching of Medline, Embase, the Cochrane Central Register of Controlled Trials and the Web of Science of articles published between 31 January 1992 and 31 January 2012. Search terms included transfusion, blood loss, spine tumour surgery, metastatic spinal disorder. Only papers

in English language which clearly presented blood loss data in a spine tumour surgery were included. The random eff ects model was used to obtain the pooled estimate of mean blood loss.

Results: There were 760 patients who had undergone major spine tumour surgery. The pooled estimate of blood loss during spinal tumour surgeries was 2180 ml (95% CI: 1805 to 2554). Apart from two studies which reported signifi cant mean blood loss of more than 5500 ml, the resulting funnel plot suggested absence of publication bias. This was confi rmed by Egger’s test which did not show any small-study eff ects (p=0.119). However, there was strong evidence of heterogeneity between studies with I2=90% (p<0.001).

Conclusions: Spine tumour surgery is associated a signifi cant average volume of blood loss and the possibility of unprecedented catastrophic blood loss. There is a need to establish standardized methods of calculating and reporting intra-operative blood loss, so that a more comprehensive and accurate analysis can be conducted to estimate blood loss by spine area involved, surgical technique and type of tumour. Such information would be benefi cial in the pre-operative planning of blood replenishment during surgery.

Effi cacy of Intraoperative Epidural Steroids in Lumbar Discectomy: A Systematic Review

Presentation by Bakur A. Jamjoom, Abdulhakim B. Jamjoom

University Hospitals Coventry and Warwickshire NHS Trust

Introduction: This study is a descriptive systematic review of the literature aimed at examining the effi cacy of the use of intra-operative epidural steroids in lumbar disc surgery, a matter that remains controversial.

Methods: Relevant clinical trials were selected from databases and reviewed. The quality of each study was assessed for perceived risk of bias. All documented signifi cant and non-signifi cant fi ndings were collected. Outcome targets were pain scores, consumption of analgesia, hospital stay and complication rates. Variation in the timing of pain assessment necessitated grouping the outcome into three stages; early: up to 2 weeks, intermediate: more than 2 weeks to 2 months and late: more than 2 months to1 year.

Results: Sixteen randomized controlled trials published from1990 to 2012 were eligible. At least one signifi cant reduction in pain scores was reported in nine of the eleven

trials that assessed pain in the early stage, in four of the seven trials that assessed pain in the intermediate stage and in two of the eight trials that assessed pain in the late stage. Seven of the nine trials that looked at consumption of analgesia reported a signifi cant reduction while six of the ten trials that examined the hospital stay reported signifi cant reduction. None of the trials reported signifi cant increase of steroid-related complications.

Conclusions: There is relatively strong evidence that intraoperative epidural steroids are eff ective in reducing pain in the early stage and in reducing consumption of analgesia. There is also relatively strong evidence that they are ineff ective in reducing pain in the late stage and in reducing hospital stay. The evidence for their eff ectiveness in reducing pain in the intermediate stage is relatively weak. The heterogeneity between trials makes it diffi cult to make undisputed conclusions and it indicates the need for a large multicentre trial with validated outcome measures at fi xed time intervals.

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Lumbar Spinal Stenosis and the Effi cacy of Nerve Root Blocks for Radicular Pain: Is it Time we Used a Prognostic Index?

Presentation by Budd H, Wood R and Cumming D

Ipswich Hospital

Purpose: Nerve root blocks are commonly employed to relieve lumbosacral radicular leg pain in patients with lateral recess and foraminal stenosis before surgery is considered. While selective nerve root blocks can provide diagnostic information their effi cacy to provide initial treatment remains unclear. This study aims to defi ne the sub-group of spinal stenosis patients for which nerve root block is ineff ective and early surgery preferable.

Methods: We have retrospectively assessed the MRI scan of 148 patients undergoing lumbar nerve root block in our institution and evaluated the correlation between patient demographics, pre-operative leg pain scores, the severity of lateral recess and foraminal stenosis on MRI and the success or failure of this treatment at early follow-up. Results: The

mean patient age was 67.4 years with a male : female ratio 0.6:1. Twenty-four percent of patients went on to be booked for surgical management at early follow-up with the degree of lateral recess and foraminal stenosis signifi cantly worse in this patient group and a tend towards multilevel disease, higher mean age, previous failed injection treatment and single level injection.

Conclusions: We propose that a prognostic index can be formulated considering radiological and demographic parameters to assist in early decision making for these patients and avoid unnecessary and costly procedures.

The role of oblique (type 4) spinous process abutment in the aetiology of degenerative lumbar scoliosis

Presentation by PAG Torrie, R Purcell, SJ Morris, IJ Harding, P Dolan, MA Adams, IW Nelson,MJ Hutchinson

Frenchay Hospital, Bristol

Purpose: To determine if patients with lumbar coronal plane deformity have a higher prevalence of oblique spinous process abutment (SPA) compared to controls. Method: This was a retrospective case/control study of 1501 consecutive CT lumbar spine scans. 250 patients aged over 40 years who had a standing lateral plain fi lm lumbar radiograph and lumbar CT scan within one year was included. Measurements of lumbar coronal plane angle (LCPA) and Interspinous gap height (ISGH) were obtained from the radiographs. SPA was defi ned as an ISGH of <3mm. SPA subtype, categorised from 0 (absent) to 4 (oblique), were determined from CT scans. “Cases” (n=125) were defi ned as patients with a lumbar coronal plane angle of >10°. ISGH and SPA subtype were recorded at each lumbar level. Prevalence of SPA in cases versus controls was compared using the Chi squared test. Predictors of LCPA were identifi ed using stepwise multiple regression. Signifi cance was accepted at P<0.05.

Results: The prevalence of SPA (types 1-4) was higher in cases than controls (63.1% vs 32.3% respectively, P><0.0001), as was the prevalence of oblique (type 4) SPA (28.9% vs 7.3% respectively, P><0.0001). The CT ISGH was signifi cantly reduced in the case group compared to controls (2.80mm vs. 4.41mm respectively, P><0.0001). Signifi cant predictors of lumbar coronal plane angle were age (P><0.0001) and SPA type 4 (P=0.006). Mean ISGH was not quite signifi cant (P=0.077).

Conclusions: Results of this study show that SPA subtype may be an important risk factor in the development of degenerative lumbar scoliosis. The infl uence of oblique SPA on the LCPA suggests that asymmetrical loading of the posterior elements of the spine may contribute to curve development and progression in older people.

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Outcomes of lumbar microdiscectomy by a single spinal surgeon service in a district general hospital

Presentation by O.Riaz, H.Phillips, K.Muralikuttan

Huddersfi eld Royal Infi rmary

Aim: Microdiscectomy is considered to be the gold standard of surgical intervention for lumbar disc herniation with radiculopathy. It is the most common procedure performed at Neurosurgical centres. We report our outcome data for lumbar microdiscectomy performed by a single Orthopaedic Spinal Surgeon service operating in a District General Hospital (DGH).

Method: Retrospective review of 150 patients who were prospectively scored with lumbar disc herniation treated with microdiscectomy between January 2007 and December 2012. After neurological examination, all patients were investigated with MRI of the lumbosacral area to correlate the clinical level and operated by our senior author. Preoperative and postoperative Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores were recorded for back pain and leg pain during clinic follow-up.

Results: 150 patients, 67 females/83 males, age from 15 to 79, mean 41.8. Most common level was L5-S1 76/150 (50.6%), followed by L4-L5 54/150 (36.0%), multiple levels 10/150 (6.7%), L3-L4 6/150 (4.0%), and L2-L3 4/150 (2.7%). At 6 weeks follow-up, 99/150 (66.0%) were discharged, pre-op mean ODI 56 which improved to 20 upon discharge, pre-op VAS back pain improved from 6.3 to 2.3, right leg pain (for right-sided operations) improved from 7.8 to 1.8, and left leg pain (for left-sided operations) improved from 7.9 to 1.4. 29/150 (19.3%) were discharged at 6 months and 8/150 (5.3%) discharged after 1 year. 9/150 (6.0%) having ongoing follow-up, and 5/150 (3.3%) referred to tertiary centre for further management. Complication rates, infection 9/150 (6.0%) (3/150 discitis, and 6/150 superfi cial wound infection), dural leak 2/150 (1.3%), revision 4/150 (2.7%), and re-admission 8/150 (5.3%).

Conclusion: Results of microdiscectomy performed by a single surgeon service at a DGH yields a high discharge rate of 85% at 6 months post-op with complication rates comparable with tertiary centres. We belief this is a safe operation to be undertaken in a district hospital level setting.

Artifi cial disc replacement versus fusion in the cervical spine: A systematic review of systematic reviews

Presentation by Khaled Aneiba

University Hospital of North Teeside

Background:Anterior cervical discectomy and fusion (ACDF) is a relatively safe and eff ective procedure to treat disk disease in the cervical spine by decompressing the neural element in the aff ected segment. However, numerous complications were reported arising from this procedure. This includes dysphagia, dislodgement or fracture in the aff ected segment or an increase of motion and Load at the adjacent levels of the cervical spine. To off er an alternative with less complications cervical artifi cial disc replacement (C-ADR) has been introduced in 2002. In the last decade there were several studies and reviews to compare the two procedures head to head and to evaluate whether the new procedure lead to less complications, better clinical outcomes and more patients’ satisfaction. Aim: To review and evaluate the fi ndings of published systematic reviews and meta-analyses which attempted to compare the clinical outcomes of C-ADR versus ACDF.

Methods: A combination of the following keywords was used in the search for systematic reviews: (total disk replacement, prosthesis, implantation, discectomy, arthroplasty) and (cervical vertebrae, cervical spine, spine) and (pain, disability, quality of life) and (systematic reviews, reviews, meta-analysis) . These keywords were used as MESH headings where appropriate. The search was conducted on the 18 August 2013 by a Cochrane trained academic librarian.The following databases were searched: [Medline via Ovid, Embase, Cochrane Database of Systematic Reviews, Google scholar]. Manual search of reviews and discussion articles and case studies were also attempted by the two authors. The authors screened the

results of the search independently according to pre-designed eligibility criteria. For the article to be selected for further consideration it has to be a systematic review and/or meta-analysis of randomised controlled trials that attempted to compare between the two interventions at the cervical region.

Results: The electronic search produced 881 hits of which 145 were duplicates. Initial screening of the abstracts resulted in selection of 68 articles for further evaluation. Five more articles were identifi ed through manual search. The fi nal judgement of the two reviewers was to include 10 systematic reviews and/or meta-analyses in this overview. The number of randomised trials reviewed by the selected reviews varies from 2 to 27. Other discrepancies between the reviews included: the follow up period, the outcomes considered and reporting of heterogeneity or publication bias of the included studies. Eight reviews and meta-analyses concluded that overall C-ADR is more eff ective and probably superior to ACDF specifi cally in neurological success, low rate of secondary operation and most pain outcomes. One meta-analysis concluded that ACDF is associated with shorter operative time and less blood loss compared to C-ADR. However, a Cochrane review critically evaluated the diff erences between the clinical outcomes of the two interventions and while confi rmed that C-ADR superiority may be statistically signifi cant in many of these outcomes, the diff erences between C-ADR and ACDF is small. This was also evident in all meta-analyses evaluated here. Conclusion: C-ADR may be superior, or at least equivalent, to ACDF in most clinical and patients’ outcomes but the eff ect size of the diff erence is small and more time and research is needed to reach a defi nitive conclusion. A robust systematic reviewing is also recommended.

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Management of Metastatic Spinal Cord Compression (MSCC) in a University Teaching Hospital

Presentation by Sujay Dheerendra, Daniel Jordan, Sanam Qasem, Mark Mcgowan, Antonino Russo, Robin Pillay, Donal O Donoghue, Marcus deMatas

Walton Hospital, Liverpool

Aim: The aim of this study is to prospectively evaluate the management of patients presenting with MSCC to a university teaching hospital and compare the outcomes to a similar study in the same unit in 2002.<?

Methods: The data was collected, between September 2010 and August 2012, prospectively by the MSCC co-ordinator. The data included patient demographics, Frankel, Barthel, VAS & Karnofsky scores and Tokuhashi staging, pre-treatment with reassessment on discharge & at 3 month follow up.

Results: 2012: There were 60 patients with MSCC with an average age of 69. The patients were divided into surgery (n=15) and radiotherapy (n=37) groups. The remaining patients (n=8) were managed palliatively. The median Tokuhashi score

for surgery was 8 and radiotherapy was 7, demonstrating a signifi cant diff erence (p<0.05). The VAS and Karnofsky scores were signifi cantly better on discharge after treatment and did not change at 3 month follow-up. Median survival of patients in the surgery group was 147 days and 58 days for patients in radiotherapy group. The median time to obtain a MRI scan from the time of referral was 15.38 hours.

2002: There were 38 patients with an average age of 58.9 years. 24 were in surgery group and 14 were in the radiotherapy group. The median Tokuhashi score for surgery (9) and radiotherapy (7) groups were signifi cantly diff erent. The Oswestry disability score and SF36 were signifi cantly better in patients in the surgical group at 3 and 6 month follow-up

Conclusion: Spinal surgery for metastatic spinal disease in our unit clearly provides improvement in quality of life. The surgical staging and assessment allows the selection of patients who benefi t most from surgery as shown by the median survival and functional outcome scores. The timing of investigations has not greatly changed the outcome of patients in the long term.

Please note: This presentation has been withdrawn

Can we measure effi cacy of caudal epidural injection for low back pain using para-spinal muscle mass and fatty degeneration?

Presentation by Muhammad Ul Haq, Syed Haque, Umar Mohammed, Nana Osei

Trauma & Orthopaedics Luton & Dunstable NHS Trust

Introduction: Low back pain is a common presentation to practitioners. The prevalence of low back pain - the point prevalence ranged from 12% to 33%, up to 65% for 1- year prevalence, and 84% for lifetime prevalence¹. Of the numerous therapeutic modalities available for management of chronic low back pain including operative intervention, the epidural administration of corticosteroids is regularly performed in specialist centres and has been used since 1953. Despite the longitivity of this treatment there is no specifi c predictor of its outcome.

Design: Single centre, prospective

Objectives: We aimed to fi nd the relationship between short term pain relief and fatty degeneration in para-spinal muscle in patients undergoing caudal epidural injection. Methods: Between Jan 2013 and Oct 2013, 103 (48M, 55F) patients were

included who underwent caudal epidural steroid injection for chronic back pain associated with disc pathology, facet degeneration and spinal stenosis. Apart from the specifi c pathologies mentioned they also were given caudal epidural steroid injection. All these patients were given 80 mg of depomedrone in operating theatre under x-ray guidance. Each patient completed the visual analogue pain score and Oswestry disability index (ODI) at baseline and 6 weeks & 6 months follow up. Patients’ spinal muscle mass and fatty changes were measured using T2 weighted axial MRI Image at upper part of forth lumber vertebra.

Results: The results were analysed using statistical tests. Patients having more than 35 % fatty tissue in the spinal muscle did not do well with caudal epidural steroid injection as compared to patients having higher percentage of muscle mass.

Conclusion: Our study helps in predicting the responders and non-responders to caudal epidural steroid injection. Orientation of para-spinal muscle mass and fat status may be critical for the caudal epidural injection.

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Good Outcomes of Percutaneous Fixation of spinal fractures in Ankylosing Spinal Disorders

Presentation by David Yeoh, FRCS, BSc Tapiwa Moff att, MBBS Shuiab Karmani, FRCS

Conquest Hospital East Sussex

Introduction: The ankylosed spine is prone to trauma even with only seemingly minor trauma. Multi-level vertebral bony fusions produce long lever arms, susceptible to fracture, with an increased risk of neurological injury. Additional problems result from delayed presentation and osteoporosis. These patients are also often at high risk of complications, making conventional open spinal surgery less appealing. We present the outcomes of percutanous fi xation and its advantages in this high risk group of patients.

Methods: A retrospective review of a series of 11 patients with a diagnosis of either ankylosing spondylitis or diff use idiopathic skeletal hyperostosis (DISH). All patients had sustained a spinal fracture between January 2009 - January 2013 and underwent percutaneous fi xation using Medtronic longitude system

(Minneapolis, USA) with Polyaxial screws. All were followed up with outcomes, complications and functional scores, (Oswestry Disability Index (ODI) and Pain Visual Analogue scores (VAS).

Results: The mean patient age was 72. There was a delayed presentation in seven patients, of which two presented with neurological compromise. The neurological defi cit did not change with surgery and there were no neurological complications as a result of surgery. The mean length of stay was 24 days, with no direct surgical complications. The mean drop in haemoglobin level was 2.4, with three patients requiring a blood transfusion. The patients were followed up to a mean of 23 months, with a mean ODI of 15.2 and pain VAS of 1.4. At the time of follow up, two patients had died with no loss to follow up.

Discussion: Even minor trauma can result in fracture in the ankylosed spine, requiring a high index of suspicion from the physician. The risks of missing such a fracture are signifi cant neurological injury.The biomechanics of the spine are signifi cantly altered, and treatment is demanding. We propose that minimally invasive spinal surgery can achieve good outcomes, low complication rates and high rates of satisfaction.

Modic change before and after dynesys

Presentation by Lucy Cooper, John Shepperd, Arash Aframian

East Sussex Health Care NHS Trust

Introduction: We report a series of patients who underwent Dynesys stabilisation. MRI examination was undertaken pre and post procedure. The purpose of the investigation was to assess progression of the MRI changes post instrumentation.

Method: Of all Dynesys procedures performed in our unit between 2006 and 2012, nine patients had an MRI scan during follow up. All of these cases had been entered into our prospective database. This included pre-operative clinical profi le, using eight measuring instruments, and regular repeat profi ling at follow up.

Results: Six of the MRI scans demonstrated signifi cant resolution of modic change. One MRI scan showed no diff erence in modic change. Two MRI scans showed increased modic change, one of whom had undergone additional posterior lumbar interbody fusion at the level above. The second patient later had the dynesys system removed, and

replaced with interbody fusion. Discussion: The association between Modic Change and back pain has been previously reported (Boos). Resolution of Modic change might therefore be associated with improvement in symptoms. Our unit previously reported a cadaver study in which Modic change was associated with endplate cartilage ulceration. Dynesys stabilisation reduces the shearing forces which are a possible aetiology of this ulceration. This study indicates one possible factor in the benefi cial eff ect of this procedure.

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Posters And Exhibition Floor Plan – Butterworth Hall

14.7m

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Posters And Exhibition Floor Plan – Mead Gallery

Exit

Entry

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To Service lift

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Catering

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17WR WR WR

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Gold 1. Stryker

Silver 2. NuVasive

Silver 3. Globus Medical

Bronze 4. Medicrea

5. Melyd Medical

6. Integralife

7. Eurospine

8. BIOMET

9. Zimmer Ltd

10. Q Spine

11. Shine Charity

12. Tiger Medical

13. EOS Imaging

Gold 14. DePuy Synthes

15. Brainlab

Bronze 16. Spineart

17. United Open MRI Ltd

WR = Welcome Reception – Industry Speed Dating

1. Ranier Technology

2. Sawbones Worldwide

3. Lindare Medical

4. Mercian Surgical

5. Trimedica

6. Premia Spine

Gold 7. Medtronic UK Ltd

8. DGL Solutions

9. Alphatec Spine

10. MBA Surgical

11. EuroSpine (SSE), BSR,

Cauda Equina Syndrome & SAUK/BSRF

12. NHS Blood and Transplant (NHSBT)

13. Spring active

14. Relaxback UK

15. NeuroTherm

16. SpineVision

17. Supra Medical

18. Highland Medical Ltd

19. Fannin UK Ltd

20. Macromed UK Ltd

21. B. Braun Medical Ltd

22. Intrinsic Therapeutics Inc

23. The RealHealth Institute

Gold 24. K2M

25. Vexim

26. Carl Zeiss

WR = Welcome Reception – Industry Speed Dating

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Exhibitors’ Profi les

BritSpine 2014 gratefully acknowledges the generous contribution that the sponsors have made to make this event possible.

Gold Sponsors

DePuy Syntheswww.depuysynthes.comStand No 14 Butterworth Hall

DePuy Synthes Companies of Johnson & Johnson is the largest, most innovative and comprehensive orthopaedic and neurological business in the world. DePuy Synthes Spine off ers a comprehensive portfolio of spinal care solutions for the treatment of the most simple to the most complex spine disorders using traditional and minimally invasive techniques.

K2M Incwww.k2m.comStand No 24 Mead Gallery

K2M Inc is the largest privately held spinal device company in the world focused on the research, development, and commercialisation of innovative solutions for the treatment of complex spinal pathologies and minimally invasive procedures. The company is recognized as a global leader in providing unique technologies for the treatment of deformity, degenerative, trauma and tumour spinal patients. K2M’s product development pipeline includes: spinal stabilisation systems, minimally invasive systems, biologics and other advancing technologies, such as motion preservation, annular repair and nucleus replacement.

Medtronicwww.medtronic.co.ukStand No 7 Mead Gallery

At Medtronic, we’re changing what it means to live with chronic disease. We’re creating innovative therapies that help patients do things they never thought possible. Seeing our work improve lives is a powerful motivator. The more we do, the more we’re driven to push the boundaries of medical technology.

Stryker Spinewww.stryker.co.ukStand No 1 Butterworth Hall

Stryker is one of the world’s leading medical technology companies and, together with our customers, we are driven to make healthcare better. The company off ers a diverse array of innovative medical technologies, including reconstructive, medical and surgical and neurotechnology and spine products to help people lead more active and more satisfying lives. Stryker products and services are available in over 100 countries.

Exhibitors’ Profi les

Silver Sponsors

Globus Medicalwww.globusmedical.comStand No 3 Butterworth Hall

Globus Medical Inc is a leading musculoskeletal implant manufacturer and is driving signifi cant technological advancements across a complete suite of spinal products. Founded in 2003, Globus’ single-minded focus on advancing spinal surgery has made it the fastest growing company in the history of orthopaedics.

NuVasivewww.nuvasive.comStand No 2 Butterworth Hall

NuVasive off ers a comprehensive spine portfolio of over 80 unique products developed to improve spine surgery and patient outcomes. The company’s principal procedural solution is its Maximum Access Surgery, or MAS® platform for lateral spine fusion. MAS provides safe, reproducible and clinically proven outcome.

Bronze Sponsors

MEDICREA www.medicrea.comStand No 4 Butterworth Hall

MEDICREA is a fully-dedicated spinal implant company focused on introducing reliable and innovative technologies to the global marketplace. With over 15 years of experience, MEDICREA provides a full range of patented products that are conceived, developed and manufactured to advance patient outcomes and support the work of medical professionals.

Spineartwww.spineart.comStand No 16 Butterworth Hall

Spineart off ers a complete range of Swiss made fusion, motion and minimal invasive spinal implants worldwide. Spineart provides surgeons with unique surgical solutions to spinal pathologies, combining traceable barcoded sterile packed implants with ultra-compact instrumentation.

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Exhibitors’ Profi les

Alphatec Spinewww.alphatecspine.comStand No 9 Mead Gallery

Alphatec Spine is focused on the design, development, manufacturing, and marketing of products for the surgical treatment of spine disorders, with a focus on treating conditions aff ecting the aging spine. Our broad product portfolio and pipeline includes a variety of spinal disorder products and systems.

B Braun Medical Ltdwww.bbraun.co.ukStand No 21 Mead Gallery

B Braun Medical Ltd is a member of the B Braun Group, one of the world’s leading healthcare companies. B Braun manufacture and distribute on a global basis, employing more than 49,000 people worldwide. Our global message – Sharing Expertise – clearly identifi es our philosophy of the transfer of knowledge.

Biometwww.biomet.co.ukStand No 8 Butterworth Hall

Biomet Spine is pleased to announce its acquisition of Lanx Inc, a leader in minimally invasive techniques and technologies. This acquisition will help improve our portfolio of innovative and complementary products.

Please visit the Biomet stand at BritSpine to see the LANX Aspen Spinous Process Fusion device.

Brainlabwww.brainlab.comStand No 15 Butterworth Hall

Brainlab develops, manufactures and markets software-driven medical technology supporting targeted, less-invasive treatment. Core products are image-guided systems and software used for surgical navigation, radiosurgical planning and delivery. Brainlab technology drives collaboration between hospitals and clinicians from a variety of specialties - neurosurgery, oncology, orthopedics, ENT, CMF and spine and trauma.

British Spine Registrywww.bsrcentre.org.ukStand No 11 Mead Gallery

Spinal surgery can change a person’s life. Many diff erent operations are available for a host of spinal problems. Thousands of spinal operations are performed every year in the UK. The British Spine Registry was set up by the British Association of Spine Surgeons to monitor the outcomes of spinal procedures.

Carl Zeisswww.zeiss.co.ukStand No 26 Mead Gallery

Carl Zeiss is one of the world’s leading medical technology companies. In the fi eld of microsurgery we provide innovative visualisation solutions with our range of OPMI® surgical microscopes and the EyeMag® surgical loupes. Come to our stand and participate in our contest for a chance to win a pair of ZEISS binoculars.

Cauda Equina Syndrome UKwww.caudaequinauk.comStand No 11 Mead Gallery

We are the UK’s fi rst and only registered Charity for Cauda Equina Syndrome (CES) and are committed to raising awareness of this often debilitating condition which can eff ect anyone, at any time, regardless of age, gender or fi tness level. The Charity was founded in October 2011 by Annie Glover, a suff erer of CES for three years.

DGL Solutionswww.dglit.comStand No 8 Mead Gallery

DGL Solutions is a specialised software provider for the private medical sector. Its comprehensive software suite provides consultants, secretaries, clinical staff and management with a total solution, from booking to billing, through diagnosis and treatment. Its software is intuitive and easy to use, enabling your practice to run more effi ciently.

EOS Imagingwww.eos-imaging.comStand No 13 Butterworth Hall

The EOS® system is the fi rst imaging solution designed to capture simultaneous bilateral long length images, full body or localised, of patients in a weight bearing position, providing a complete picture of the skeleton at very low dose exposure. EOS enables global assessment of balance and posture as well as a 3D bone-envelope image in a weight-bearing position and provides automatically over 100 clinical parameters to the orthopaedic surgeon for pre- and post-operative surgical planning.

Eurospinewww.eurospine.comStand No 7 Butterworth Hall

Eurospine is a French company pioneering world renowned innovative spinal implants such as the HRCC stand alone cervical cages. We are currently looking for suitable partners in the UK to expand our current well established market share.

EUROSPINE, the Spine Society of Europewww.eurospine.orgStand No 11 Mead Gallery

The aims of EUROSPINE are to stimulate the exchange of knowledge and ideas in the fi eld of research, prevention and treatment of spine diseases and related problems and to coordinate eff orts undertaken in European countries for further development in this fi eld.

Fannin UKwww.fannin.euStand No 19 Mead Gallery

Fannin is pleased to announce the formation of a brand new dedicated spinal division. We are now exclusive distributors for Paradigm non fusion products like Cofl ex, Signus Spinal Implants including Rabea and Spineview Endoscopic Spinal Surgery for disc herniation and Foramenal stenosis.

Highland Medicalwww.highlandmedical.co.ukStand No 18 Mead Gallery

Highland Medical is the proud sole distributor of the X-Spine products. We pride ourselves on our superior spinal products, excellent service and support, including cadaver labs in the US and Salzburg which shows our commitment to education. We look forward to meeting each and everyone of you at BritSpine 2014!

Exhibitors’ Profi les

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Exhibitors’ Profi les

Integralifewww.integralife.comStand No 6 Butterworth Hall

Integra proposes innovative solutions for the treatment of spinal pathologies associated with a complete biological product range enabling bone regeneration. Integra off ers a wide range of implants and bone substitutes that facilitate the treatment of the degenerative, scoliotic and traumatic/tumoral spine.

Intrinsic Therapeuticswww.in-thera.comStand No 22 Mead Gallery

Intrinsic Therapeutics’ Barricaid® implant is designed to close large anular defects which often lead to recurrent herniation following discectomy. The Barricaid® allows surgeons to perform a limited nucleotomy in every patient, thereby preserving biomechanics, while preventing reherniations by securely closing the anular defect.

Lindare Medicalwww.lindaremedical.co.ukStand No 3 Mead Gallery

Lindare Medical is proud to once again be supporting this prestigious event. Endoscopic Spine Surgery is revolutionising the way in which spine surgery is performed - and don’t be fooled into thinking its limitations are discectomies. To learn more about future developments, come and see for youself.

Macromedwww.macromed.co.ukStand No 20 Mead Gallery

Macromed is a specialist spine intervention organisation with the facility to provide full cadaveric and live case training and an extensive product range which includes distractible VBR cages, anterior plates and a full series of occiput to sacral posterior screw-rod systems for degenerative, trauma and cancer indications.

MBA UKwww.mba.eu/en/units/mba-ukStand No 10 Mead Gallery

MBA UK is an innovative and independent orthopaedic distribution company specialising in spinal implants and lower limb arthroplasty. We pride ourselves on the level of service we off er to our customers and making a contribution towards positive patient outcomes is at the forefront of everything we do.

Melyd Medicalwww.melydmedical.comStand No 5 Butterworth Hall

Melyd Medical was established in 1996 specialising in patient positioning, accessories and operating tables. Allen Medical produces some of our main products including the Allen Advance Table, with rotation, the Allen Flex Frame, the Allen Bow Frame and the C-Flex AP Vantage, for cervical traction. All are on show at BritSpine.

Exhibitors’ Profi les

Mercian Surgical Supply Co Ltdwww.merciansurgical.co.ukStand No 4 Mead Gallery

Mercian has been established for over 45 years with a reputation for innovative and specialised High Quality Spinal Instrumentation. We have a comprehensive range of Spinal Instrumentation for applications in the areas of Lumbar, Cervical and Anterior Spinal Surgery. Mercian Instruments are used in Spinal Surgery throughout the UK providing the highest quality Instrumentation available to the Consultant.

Morgan Steer, formally Trimedica Ltdwww.trimedicaltd.co.ukStand No 5 Mead Gallery

Morgan Steer, formally Trimedica Limited, is the exclusive distributor of the RTI Surgical (formally Pioneer) range of spinal implants. Included in our portfolio is the NuNec PEEK CDR or an alternative, the NanOss C has been designed using innovation and biomechanics to create a Nanocrystalline Hydroxyapatite Cervical Cage.

NHS Blood and Transplant (NHSBT)www.nhsbt.nhs.ukStand No 12 Mead Gallery

NHS Blood and Transplant (NHSBT) is a Special Health Authority. We manage the national voluntary system for blood, tissues, organs and stem cells turning these precious donations into grafts that can be used safely to the benefi t of the patient. We off er a wide range of tissue for grafting/transplantation in various specialties including orthopaedics, burns, cardiovascular, ocular. Our orthopaedic grafts include femoral heads, tendons, ground bone and demineralised bone matrix (DBM) paste and putty. Why you should come to us fi rst: ethically sourced from UK donors; from the NHS for the NHS; use with confi dence - a specialist service provided direct from the NHS’s own Tissue Service Largest Tissue Bank in the UK.

NeuroThermwww.neurotherm.comStand No 15 Mead Gallery

NeuroTherm is a leading medical device company focused on developing and delivering less invasive treatments for chronic pain. The company off ers innovative solutions including radiofrequency ablation systems, intradiscal therapies, and vertebral compression fracture treatments in more than 65 countries.

Premia Spinewww.betterthanspinalfusion.co.ukwww.premiaspine.comStand No 6 Mead Gallery

Premia Spine is commercialising the TOPS™ System, a posterior lumbar device for spinal stenosis and spondylolisthesis. TOPS is a mobile implant that recreates fl exion, extension, lateral bending, axial rotation and sagittal translation. Patients experience immediate and sustained pain relief and function, as demonstrated by clinical trials since 2005.

QSpinewww.qspine.co.ukStand No 10 Butterworth Hall

QSpine manufactures and distributes a comprehensive range of products for use in spinal surgery. As well as our own lumbar stabilisation system, SMS, we are featuring the unique single use pedicle screw and instrumentation system – STERISPINE. We will also be launching the latest generation of the revolutionary bone substitute I-Factor.

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Exhibitors’ Profi les

Ranier Technologywww.ranier.co.ukStand No 1 Mead Gallery

Cadisc® key features: A unique, graduated modulus designed to mimic the natural disc form; Physiological, progressive bending stiff ness; No metallic endplates or articulating wear surfaces; Mobile centre of rotation for load-sharing biomechanics; Conformable endplates to help reduce stress-shielding; Excellent X-ray and MRI visualisation

RealHealthwww.realhealth.org.ukStand No 23 Mead Gallery

RealHealth run residential CPPs (Combined Physical and Psychological Programmes) which are either Functional Restoration (FRP) or Pain Management (PMP) focussed from a Treatment Centre in the East Midlands. These programmes are run by a multi disciplinary team of Clinicians including Consultant Pain Doctor, Clinical Psychologist, Senior Physiotherapist, Pain Physiotherapist and Sports Physiotherapist. They are suited to clients with persistent mechanical low back pain (FRP) or clients with persistent pain and complex problems aff ecting their quality of life (PMP). Outcomes are recorded against NICE guidelines and regularly published. RealHealth is recognised by most major private health insurers .

Relaxback UKwww.relaxbackuk.moonfruit.comStand No 14 Mead Gallery

The Back App chair strengthens the core muscles that support your spine. The sitting position ensures a posture that dramatically reduces muscle fatigue, keeps you comfortable allowing you to work at your desk productively. Swedstyle adjustable height desks allow you to work standing or sitting and work effi ciently in conjunction with a Back App.

SAUK & BSRFwww.sauk.org.ukwww.bsrf.co.ukStand No 11 Mead Gallery

The Scoliosis Association (UK) (SAUK) and the British Scoliosis Research Foundation (BSRF) became affi liated in 2006. SAUK is the only national charity for people aff ected by scoliosis, providing support and raising awareness of the condition. The BSRF is the only charity in the UK leading research into the causes and treatment of scoliosis and allied conditions.

Sawbones Europewww.sawbones.comStand No 2 Mead Gallery

Sawbones Europe AB is a Sales & Marketing division of Pacifi c Research Laboratories, Inc (PRL). Sawbones Europe AB sells and markets orthopaedic and medical models in the EMEA markets since 1977. The offi ce is located in Malmö, Sweden. The US offi ce, PRL, with onsite production, is situated on Vashon Island, WA, USA.

Shinewww.shinecharity.org.ukStand No 11 Mead Gallery

Shine is a registered charity, which was formed in 1966, initially to help families and individuals aff ected by spina bifi da and hydrocephalus. Today, Shine is a community of 75,000 individuals, families, friends, and professionals, sharing achievements, challenges and information on living with hydrocephalus, or spina bifi da, and related issues.

Exhibitors’ Profi les

SpineVisionwww.spinevision.netStand No 16 Mead Gallery

Headquartered in France, SpineVision® is a privately owned, integrated spinal technology company focused on development and marketing of innovative products and is the only manufacturer off ering a dynamic stabilisation system that can be used in a percutaneous approach. The Company has subsidiaries in Belgium, Germany, Italy, UK and USA.

Spring Activewww.springactive.comStand No 13 Mead Gallery

Spring Active™ is the UK’s only provider focusing on delivering a high quality complete pathway of CPP Programmes for the management of non-specifi c back pain in line with national guidelines. We look forward to discussing with you how our high intensity, low intensity and self-management programmes can assist your patients as well as sharing our approach to outcome measurement and future research.

Supra Medicalwww.supramedical.co.ukStand No 17 Mead Gallery

Supra Medical off ers products for minimally invasive spinal surgery both fusion and non-fusion. We specialise in trans-facet pedicular compression for posterior stabilisation, Pars fracture repairs, treatment of DDD and lumbar stenosis, lumbar interbody fusion, articulating TLIF cages and a pedicle screw designed to be used minimally invasively or open.

Tiger Medical Supplies www.tigermedicalsupplies.co.ukStand No 12 Butterworth Hall

Tiger Medical Supplies is focused to supplying the consultants and hospitals with the service, quality and support that is required. Visit our stand in Butterworth Hall to learn more about I-Fuse Sacro iliac fusion system, TiNano cages and Zip fusion device.

United Open MRI Ltdwww.uprightmri.co.ukStand No 17 Butterworth Hall

Upright MRI scanners in Leeds and London use the latest technology to scan patients in weight-bearing positions. These scanners bring enormous benefi ts to claustrophobic, bariatric and anxious patients thanks to their very open design. Upright MRI enables more patients than ever before to benefi t from the diagnostic imaging they need.

Veximwww.vexim.fr/enStand No 25 Mead Gallery

Vexim, a European company dedicated to providing clinically and scientifi cally proven solutions for minimally invasive procedures for patients suff ering from VCF. We specialise in the anatomical restoration of vertebrae in order to relieve pain and rebalance spine. Innovation, safety and clinical validation are priorities. SpineJack® system and Cohesion® bone cement, two of the innovative products developed by Vexim.

Zimmerwww.zimmer.com/en-GBStand No 9 Butterworth Hall

A global leader in spine innovation, Zimmer Spine has built a tradition of pride, trust and respect with skilled surgeons to enhance the quality of life for spine patients worldwide.

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Exhibitors’ Names and Stand Numbers

Stand No 14 Butterworth Hall Gold Sponsor DePuy Synthes

Stand No 24 Mead Gallery Gold Sponsor K2M Inc

Stand No 7 Mead Gallery Gold Sponsor Medtronic

Stand No 1 Butterworth Hall Gold Sponsor Stryker Spine

Stand No 3 Butterworth Hall Silver Sponsor Globus Medical

Stand No 2 Butterworth Hall Silver Sponsor NuVasive

Stand No 4 Butterworth Hall Bronze Sponsor MEDICREA

Stand No 16 Butterworth Hall Bronze Sponsor Spineart

OTHER SPONSORS – BUTTERWORTH HALL

Stand No 8 Butterworth Hall Biomet

Stand No 15 Butterworth Hall Brainlab

Stand No 13 Butterworth Hall EOS Imaging

Stand No 7 Butterworth Hall Eurospine

Stand No 6 Butterworth Hall Integralife

Stand No 5 Butterworth Hall Melyd Medical

Stand No 10 Butterworth Hall QSpine

Stand No 11 Butterworth Hall Shine Charity

Stand No 12 Butterworth Hall Tiger Medical Supplies

Stand No 17 Butterworth Hall United Open MRI Ltd

Stand No 9 Butterworth Hall Zimmer

OTHER SPONSORS – MEAD GALLERY

Stand No 9 Mead Gallery Alphatec Spine

Stand No 21 Mead Gallery B Braun Medical Ltd

Stand No 11 Mead Gallery British Spine Registry (BSR)

Stand No 26 Mead Gallery Carl Zeiss

Stand No 11 Mead Gallery Cauda Equina Syndrome UK

Stand No 8 Mead Gallery DGL Solutions

Stand No 11 Mead Gallery EUROSPINE, the Spine Society of Europe

Stand No 19 Mead Gallery Fannin UK

Stand No 18 Mead Gallery Highland Medical

Stand No 22 Mead Gallery Intrinsic Therapeutics

Stand No 3 Mead Gallery Lindare Medical

Stand No 20 Mead Gallery Macromed

Stand No 10 Mead Gallery MBA UK

Stand No 4 Mead Gallery Mercian Surgical Supply Co Ltd

Stand No 5 Mead Gallery Morgan Steer, formally Trimedica Ltd

Stand No 15 Mead Gallery NeuroTherm

Stand No 12 Mead Gallery NHS Blood and Transplant (NHSBT)

Stand No 6 Mead Gallery Premia Spina

Stand No 1 Mead Gallery Ranier Technology

Stand No 23 Mead Gallery RealHealth

Stand No 14 Mead Gallery Relaxback UK

Stand No 11 Mead Gallery SAUK & BSRF

Stand No 2 Mead Gallery Sawbones Europe

Stand No 16 Mead Gallery SpineVision

Stand No 13 Mead Gallery Spring Active

Stand No 17 Mead Gallery Supra Medical

Stand No 25 Mead Gallery Vexim

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• Myeloma UK

• The Society for Back Pain Research

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and care programs that will help current and future spine patients.

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©2014. NuVasive, Inc. All rights reserved. , NuVasive, Speed of Innovation, and MAS are registered trademarks of NuVasive, Inc. 14-NUVA-297

Bilateral decompression, stabilization, and interbody fusion through a laminectomy exposure

NuVasive, Inc. 7475 Lusk Blvd. San Diego, CA 92121 USA phone: 800-475-9131 fax: 800-475-9134

NuVasive UK, Ltd. Suite B, Ground Floor Caspian House, The Waterfront Elstree, Herts WD6 3BS UK phone: +44 (0) 208-238-7850 fax: +44 (0) 207-998-7818 www.nuvasive.com

Dates for your Diary

2014 Jun Wed 4th-Fri 6thEFORT/BOA Combined MeetingLondon

Sep Fri 12th-Sat 13thBritish Orthopaedic AssociationBrighton

Sep Wed 17th-Fri 19thSociety of British Neurological Surgeons Autumn MeetingUniversity Hospitals, Coventry & Warwickshire

Oct Wed 8th-Fri 10thBritish Scoliosis Society Annual MeetingBristol Marriott Royal Hotel

Nov Thu 6th-Fri 7thSociety for Back Pain ResearchRadisson Blu St Helen’s Hotel - Dublin, IrelandLocal Hosts: University College Dublin

2015 Mar Wed 18th-Fri 20thBritish Association of Spine Surgeons ConferenceAssembly Rooms, Bath

Apr Tue 21st-Thu 23rdBritish Scoliosis Society Annual MeetingCity Hall, Sheffi eld

Nov Thu 5th-Fri 6thSociety for Back Pain ResearchAnglo-European College of Chiropractic - Bournemouth

2016 TBA TBABritSpineNottingham (exact venue to be announced)

TBA TBABritish Scoliosis Society Annual MeetingMiddlesbrough (exact venue to be announced)

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Notes Notes

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104 105BRITSPINE 2014BRITSPINE 2014

RA I L 4D ™ T ECHNOLOGY

MINIMALLY INVASIVE MEETS MAXIMUM VISIBILITY

WITHSTANDING THE FORCE OF TIME

VISIT US UPSTAIRS AT BOOTH 24 IN THE MEAD GALLERY TO LEARN MORE!

K2M, Inc. 751 Miller Drive SE Leesburg, Virginia 20175 USAPH 866.K2M.4171 (866.526.4171)FX 866.862.4144

©2014 K2M, Inc. All rights reserved.Actual Device Color May Vary.

Consult Product Catalog For Details.

www.K2M.com

Notes