Andrew Clarke

Primary care perceptions of the prevalence, diagnosis and management of coccydynia: Results of a web-based survey of Devon general practitioners

Abstract Purpose The purpose of this study to take a snapshot opinion of general practitioner (GP) understanding of the prevalence, diagnosis, and management of coccydynia. Methodology We designed a simple 5-question survey to administer to our local GPs. The survey was sent to 107 GP practices in Devon whose details were provided by The Devon Access Referral Team. We received 150 electronic replies. We also submitted the survey to 50 GPs who attended a study day at our institution – and ensured they had not already completed the electronic format of the same work. Thus, we received 200 replies which we believe to be a representative sample of our local GPs opinion. Results Fifty-one percent of GPs correctly identified the prevalence of the condition. Thirty-nine percent believed the condition to be associated with an underlying psychological disorder. Fifty-two percent believed there was no proven treatment for the condition. Only twenty-two percent would consider referring the patient to any secondary care service that dealt with chronic spinal pain (pain clinic, rheumatology or spinal surgery) even if the symptoms persisted beyond 3 months duration. Seventy-three percent believed surgery was madness or had a less than 20% chance of relieving symptoms. Conclusion Coccydynia is a painful condition, causing significant distress for those suffering with the condition. Primary care physicians seem reluctant to recognize the problem as significant and reluctant to refer patients for treatment that may offer significant symptomatic relief. Education about the condition is required.

The current state of the evidence for the use of drains in spinal surgery: systematic review

PurposeSearch for evidence pertaining to the effectiveness of drains used in spinal surgeries.MethodPubMed and EMBASE databases were searched for articles pertaining to the use of drains in all types of spinal surgery. The bibliographies of relevant studies were searched for additional papers that met the initial inclusion criteria. Level I and II studies were scored according to guidelines in the Cochrane Collaboration Back Review Group. We utilised the Population, Intervention, Comparison, Outcomes and Study design (PICOS) method to define our study eligibility criteria.ResultsNineteen papers were identified: four level I studies, eight level III studies and seven level IV studies. The four level I, involving the randomization of patients into ‘drain’ and ‘non-drain’ groups, identified a total of 363 patients. Seven of the eight level III retrospective studies concluded that the use of drains did not reduce complications. Two of the seven level IV studies agreed with this conclusion. The remaining five level IV studies reported the benefits of lumbar drainage following dural tears.ConclusionsThere is a paucity of published literature on the use of drains following spinal surgery. This is the first study to assess the evidence for the benefits of drains post-operatively in spinal surgery. The identified studies have shown that drains do not reduce the incidence of complications in anterior cervical discectomy and fusion, one and two level posterior cervical fusions, lumbar laminectomies, lumbar decompressions or discectomies and posterior spinal fusion for adolescent scoliosis. Further level I and II studies are needed.

Bovine and degenerated human annulus fibrosus: a microstructural and micromechanical comparison.

The complex structure of the annulus fibrosus is strongly related to its mechanical properties. Recent work showed that it is possible to observe the relative movement of fibre bundles in loaded cow tail annulus; the aim of this work was to describe and quantify annulus fibrosus micromechanics in degenerated human disc, and compare it with cow tail annulus, an animal model often used in the literature. Second harmonic generation was used to image the collagen matrix in twenty strips of annulus fibrosus harvested from intervertebral disc of seven patients undergoing surgery. Samples were loaded to 6% tensile strain in 1% steps. Elastic modulus was calculated from loading curves, and micromechanical strains were calculated from the images using custom software. The same protocol was applied to twenty strips of annulus harvested from cow tail discs. Significant morphological differences were found between human and cow tail samples, the most striking being the lack of collagen fibre crimp in the former. Fibres were also observed bending and running from one lamella to the other, forming a strong flexible interface. Interdigitation of fibre bundles was also present at this interface. Quantitative results show complex patterns of inter-bundle and inter-lamellar behaviour, with inter-bundle sliding being the main strain mechanism. Elastic modulus was similar between species, and it was not affected by the degree of degeneration. This work gives an insight into the complex structure and mechanical function of the annulus fibrosus, which should be accounted for in disc numerical modelling.

Catastrophic Cervical Spine Injuries in Contact Sports

Study Design Systematic review. Objectives To determine the incidence of catastrophic cervical spine injuries (CCSIs) among elite athletes participating in contact team sports and whether the incidence varies depending on the use of protective gear or by player position. Methods Electronic databases and reference lists of key articles published from January 1, 2000, to January 29, 2016, were searched. Results Fourteen studies were included that reported CCSI in rugby (n = 10), American football (n = 3), and Irish hurling (n = 1). Among Rugby Union players, incidence of CCSI was 4.1 per 100,000 player-hours. Among National Football League players, the CCSI rate was 0.6 per 100,000 player-exposures. At the collegiate level, the CCSI rate ranged from 1.1 to 4.7 per 100,000 player-years. Mixed populations of elite and recreational rugby players in four studies report a CCSI rate of 1.4 to 7.2 per 100,000 player-years. In this same population, the scrum accounted for 30 to 51% of total reported CCSIs in Rugby Union versus 0 to 4% in Rugby League. The tackle accounted for 29 to 39% of injuries in Rugby Union and 78 to 100% of injuries in Rugby League. Making a tackle was responsible for 29 to 80% of injuries in American football. Conclusion CCSIs are infrequent among elite athletes. There is insufficient evidence to determine the effect of protective gear (e.g., helmets, padding) on CCSI incidence. Scrum and tackle in rugby and tackling in American football account for the majority of CCSIs in each respective sport.

Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up

Abstract Background context: Transforaminal epidural steroid injection (TFESI) is recognised as a treatment for symptomatic lumbar disc herniation, whilst surgical decompression is generally thought to be the most effective treatment option for lumbar spinal stenosis. There is little available literature examining the effect of TFESI on symptomatic lumbar spinal stenosis. Purpose: To evaluate the use of TFESI as an alternative to surgery in patients with symptomatic stenosis. Study design/setting: An observational study which took place between May 2010 and July 2013. All patients were seen by the Extended Scope Physiotherapist (ESP) injection service. Patient sample: A total of 68 consecutive patients were included. Thirty-one were male and 37 were female. The average age was 75 years. Outcome measures: The primary outcome measure was the avoidance of decompressive surgery. Methods: Patients with radicular leg pain were seen by an ESP in an Outpatient setting. Concordant clinical examination and magnetic resonance imaging were required for diagnosis. Peri-radicular bupivacaine hydrochloride 0.25% (3 ml) and triamcinolone (40 mg) were then injected. Outcome measures were recorded at 6 weeks, 1 year and 2 years. Results: Of 68 patients with spinal stenosis, 22 (32%) had opted for surgery at two year follow-up. Thirty (44%) patients were satisfied with non-surgical management at 2 years, required no further treatment, and were discharged. Of the remaining 24%, nine patients were referred for further injection, four declined surgery but were referred to the Pain Relief Clinic, two still had a similar level of pain but declined surgery and one had died. Conclusions: Our study reports a considerably lower percentage patients opting for surgery than previously demonstrated by the available literature. TFESI is a reasonable treatment for lumbar spinal stenosis and can result in long-term relief from symptoms in a high proportion of patients.

The effects of needle damage on annulus fibrosus micromechanics

Needle puncture of the intervertebral disc can initiate a mechanical and biochemical cascade leading to disc degeneration. Punctures mechanical effects have been shown near the puncture site, mechanical effects should be observed far, relative to needle size, from the puncture site, given the disc-wide damage induced by the stab. The aim of this work was to quantify these far-field effects, and to observe the local structural damage provoked by the needle. Strips of cow tail annulus fibrosus underwent two consecutive mechanical loadings to 5% tensile strain; fifteen samples were punctured in a radial direction with a randomly assigned needle between the two loadings (needle gauges between 19 and 23). Ten samples (control group) were not punctured. During loading, the tissue strains were imaged using second harmonic generation microscopy in a <600×800µm region about 4.4mm from the puncture site. After mechanical testing, the puncture site was imaged in 3D. Puncture had no significant effect on annulus elastic modulus. Imaging showed a modest change in the shearing between fibre bundles however, the linear strain between bundles, intra-bundle shear and linear strain were not significantly affected. At the puncture site, detached lumps of tissue were present. These results suggest that the mechanical effects observed in intact discs are due to the depressurization of the disc, rather than the local damage to the annulus. Needle profiles could be designed, aiming at separating fibre bundles rather than cutting through them, to avoid leaving dying tissue behind. STATEMENT OF SIGNIFICANCE Needle puncture of the intervertebral disc can initiate a mechanical and biochemical cascade leading to disc degeneration, but the link between the local damage of the puncture and the disc-wide effects is not well understood. This work aimed at determining the micro-mechanical effects of the puncture far from its site, and to observe the damage induced by the puncture with high resolution imaging. Results show that the puncture had modest effect far from the puncture, but lumps of tissue were left by the needle, detached from the disc; these could cause further damage through friction and inflammation of the surrounding tissues. This suggests that the cascade leading to degeneration is probably driven by a biochemical response rather than disc-wide mechanical effects.

Erect radiographs to assess clinical instability in patients with blunt cervical spine trauma.

BACKGROUND Computed tomography (CT) and magnetic resonance imaging (MRI) are sensitive modalities for the assessment of the spine, but certain injuries remain poorly assessed with supine radiographs. We describe four cases in which cervical spine injuries were proven as unstable with erect radiographs after being previously evaluated with supine radiographs and CT scans. METHODS A retrospective review of medical records and images was used to identify four patients who presented to a teaching hospital from April to December 2010 with unstable cervical spine injuries that were only demonstrated on erect radiographs. RESULTS All four patients sustained either C4-C5 or C5-C6 injuries. Prior to diagnosis, each had been evaluated with supine radiographs that did not demonstrate instability. Computed tomography identified the osseous injuries that were present but did not provide suitable assessment of stability. Three patients successfully underwent anterior cervical discectomy and fusion. The fourth was managed with a Halo jacket because of major comorbidities. CONCLUSIONS Despite major advances in imaging, these cases highlight the importance of physiological loading and radiographs. The controlled use of erect radiographs to test for clinical instability in patients with cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated.

Respiratory failure due to a displaced fracture of the odontoid

Fractures of the odontoid peg are relatively common in elderly people. Often they are minimally displaced and can be treated with a collar. However, a fracture which is displaced significantly may be difficult to manage. We describe the case of an 80-year-old man with a fracture of the odontoid peg which was completely displaced and caused respiratory distress. After initial closed reduction and application of a halo jacket, open and internal fixation was undertaken and relieved his symptoms. It is a safe and effective way to manage this injury.

Do Growing Rods for Idiopathic Early Onset Scoliosis Improve Activity and Participation for Children

Objective To investigate whether growing rod surgery for children with progressive idiopathic early onset scoliosis (EOS) effects activity and participation, and investigate factors that may affect this. Study design Multicenter retrospective cohort study using prospectively collected data on 60 children with idiopathic EOS and significant scoliosis (defined as a Cobb angle >40°). Thirty underwent brace treatment, and 30, growth rod surgery. Questionnaire and radiographic data were recorded at 1 year. The validated Activities Scale for Kids performance version (ASKp) questionnaire was used to measure activity and participation. Results In the brace group, Cobb angle increased from 60° to 68°. There was no change in ASKp score. In the operative group, Cobb angle decreased from 67° to 45°. ASKp decreased from 91 to 88 (P < .01). Presence of spinal pain correlated with greater reduction in activity and participation scores in both groups, as did occurrence of complications in the operative group (P < .05). Both treatments permitted growth of the immature spine. Conclusions In children with significant idiopathic EOS (Cobb angle>40°), growth rod surgery was associated with a reduction in activity and participation and Cobb angle, whereas brace treatment was associated with an increase in Cobb angle and no change in activity and participation. Pain was the most important factor affecting activity and participation in both groups.

Recommendations for Lengthening of Magnetically Controlled Growing Rods in Children With Pacemakers.

Purpose of the Study: Pacemakers are currently identified as a contraindication for the use of magnetic growth rods (MGRs). This arises from concern that magnetic fields generated by the MGR external remote controller (ERC) during lengthening procedures may induce pacemaker dysfunction. We investigated (1) whether MGR lengthening affects pacemaker function, and (2) if the magnetic field of a pacemaker affects MGR lengthening. Methods: MGRs were tested in conjunction with an magnetic resonance imaging-compatible pacemaker, which was connected to a virtual patient under continuous cardiac monitoring. To determine whether pacemaker function was affected during MGR lengthening, the electrocardiogram trace was monitored for arrhythmias, whereas an ERC was applied to lengthen the MGRs at varying distances from the pacemaker. To investigate if MGR lengthening was affected by the presence of a pacemaker, at the start and end of the experiment, the ability of the rods to fully elongate and shorten was tested to check for conservation of function. Results: When the pacemaker was in normal mode, <16 cm away from the activated ERC during MGR lengthening, pacemaker function was affected by the ERC’s magnetic forces. At this distance, prophylactically switching the pacemaker to tonic mode before lengthening prevented occurrence of inappropriate pacing discharges. No deleterious effect of the pacemaker’s magnetic field on the MGR lengthening mechanism was identified. Conclusions: Magnetic resonance imaging-compatible pacemakers appear safe for concomitant use with MGRs, provided a pacemaker technician prophylactically switches the pacemaker to tonic function before outpatient lengthening procedures. Clinical Relevance: This experiment was designed to provide the first safety information on MGR lengthening in children with pacemakers. Although currently a rare clinical scenario, with increasing use of MGRs, this clinical scenario may arise more frequently in the future.