Publications by authors named "Sean Molloy"

55 Publications

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis.

Bone Joint J 2020 Oct;102-B(10):1368-1374

Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK.

Aims: Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Methods: A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples -tests, and z-tests of proportions analyses where applicable.

Results: There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches.

Conclusion: A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: 2020;102-B(10):1368-1374.
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http://dx.doi.org/10.1302/0301-620X.102B10.BJJ-2020-0273.R3DOI Listing
October 2020

Ten techniques for improving navigated spinal surgery.

Bone Joint J 2020 Mar;102-B(3):371-375

Department of Spine Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article: 2020;102-B(3):371-375.
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http://dx.doi.org/10.1302/0301-620X.102B3.BJJ-2019-1499.R1DOI Listing
March 2020

Using lean principles to introduce intraoperative navigation for scoliosis surgery.

Bone Joint J 2020 Jan;102-B(1):5-10

Department of Spinal Surgery, Royal National Orthopaedic Hospital Stanmore, Stanmore, UK.

Aims: Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery.

Methods: A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed.

Results: The greatest gains in productivity were in avoiding repeat intraoperative scans (a mean of 248 minutes for patients who had two scans, and a mean 180 minutes for those who had a single scan). Optimizing accuracy was the biggest factor influencing this, which was reliant on incremental changes to the operating setup and technique.

Conclusion: The application of lean principles to the introduction of ION for AIS surgery helps assimilate this method into the environment of the operating theatre. Data and stakeholder analysis identified a reproducible technique for using ION for AIS surgery, reducing operating time, and radiation exposure. Cite this article: 2020;102-B(1):5-10.
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http://dx.doi.org/10.1302/0301-620X.102B1.BJJ-2019-1054.R1DOI Listing
January 2020

360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity.

Global Spine J 2019 Sep 21;9(6):613-618. Epub 2018 Nov 21.

Royal National Orthopaedic Hospital, Stanmore, UK.

Study Design: Retrospective cohort study.

Objective: To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF).

Methods: Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample test and repeated-measures analysis of variance (rANOVA), was performed.

Results: Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively ( < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years ( < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years ( < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years ( = .02). There were no neurological, vascular, or visceral approach-related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture.

Conclusions: The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.
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http://dx.doi.org/10.1177/2192568218814531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693065PMC
September 2019

Delayed Presentation of a Symptomatic Psoas Hematoma Following Lumbar Vertebral Kyphoplasty for Myeloma: A Case Report.

J Orthop Case Rep 2018 Nov-Dec;8(6):74-78

Department of Trauma and Orthopaedics, Royal National Orthopaedic Hospital (Stanmore), S.M. Della Misericordia Hospital (Perugia), Italy.

Introduction: The Royal National Orthopaedic Hospital (RNOH) is a tertiary referral center and patients with spinal complications from multiple myeloma are managed here in a multidisciplinary approach. Balloon kyphoplasty(BKP) procedures are routinely performed in such patients when clinically indicated with good results and a low complication rate. There are little data reported in the literature about post-BKP hematoma formation and its management. We present the first known reported case delayed post-operative psoas hematoma in a myeloma patient following a BKP.

Case Report: A 40-year-old male patient with diagnosed Ig G lambda multiple myeloma was referred to the spinal unit based at the RNOH. An L5 fracture was deemed to be the cause of significant lower back pain. He underwent an L5BKP with good immediate results and in the absence of any immediate complications. Post-operative, the patient had normal distal neurology and was discharged1day postoperatively. 3 days after surgery, he underwent left hamstrings anterior cruciate ligament reconstruction. 2 days following the latter, he developed significant pain in his left groin and thigh associated with numbness. A pelvicmagnetic resonance imaging scan confirmed a left iliopsoas hematoma. This case was treated conservatively under guidance of the multidisciplinary team.

Conclusion: As psoas hematoma, formation is a rare complication following a BKP. The recommended management of a psoas hematoma is conservative with supportive therapy and regular clinical review. To reduce the risk of a psoas hematoma, the authors recommend that the trocar should be first placed on the transverse process and maneuvred medially to the start point on the pedicle. This would avoid injuries to the artery to the pars as well as structures deep to the intertransverse ligament avoiding this rare complication.
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http://dx.doi.org/10.13107/jocr.2250-0685.1266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424308PMC
March 2019

Neurologic Injury in Complex Adult Spinal Deformity Surgery: Staged Multilevel Oblique Lumbar Interbody Fusion (MOLIF) Using Hyperlordotic Tantalum Cages and Posterior Fusion Versus Pedicle Subtraction Osteotomy (PSO).

Spine (Phila Pa 1976) 2019 Aug;44(16):E939-E949

Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, London, UK.

Study Design: A retrospective review of prospectively collected data.

Objective: The aim of this study was to determine the safety of MOLIF versus PSO.

Summary Of Background Data: Complex adult spinal deformity (CASD) represents a challenging cohort of patients. The Scoli-RISK-1 study has shown a 22.18% perioperative risk of neurological injury. Restoration of sagittal parameters is associated with good outcome in ASD. Pedicle subtraction osteotomies (PSO) is an important technique for sagittal balance in ASD but is associated with significant morbidity. The multilevel oblique lumbar interbody fusion (MOLIF) is an extensile approach from L1 to S1.

Methods: Single surgeon series from 2007 to 2015. Prospectively collected data. Scoli-RISK-1 criteria were refined to only include stiff or fused spines otherwise requiring a PSO. Roentograms were examined preoperatively and 2 year postoperatively. Primary outcome measure was the motor decline in American Spinal Injury Association (ASIA) at hospital discharge, 6 weeks, 6 months, and 2 years. Demographics, blood loss, operative time, spinopelvic parameters, and spinal cord monitoring (SCM) events.

Results: Sixty-eight consecutive patients were included in this study, with 34 patients in each Group. Group 1 (MOLIF) had a mean age 62.9 (45-81) and Group 2 (PSO) had a mean age of 66.76 years (47-79); 64.7% female versus PSO 76.5%; Body Mass Index (BMI) Group 1 (MOLIF) 28.05 and Group 2 (PSO) 27.17. Group 1 (MOLIF) perioperative neurological injury was 2.94% at discharge but resolved by 6 weeks. Group 2 (PSO) had five neurological deficits (14.7%) with no recovery by 2 years. There were four SCM events (SCM). In Group 1 (MOLIF), there was one event (2.94%) versus three events (8.88%) in Group 2 (PSO).

Conclusion: Staged MOLIF avoids passing neurological structures or retraction of psoas and lumbar plexus. It is safer than PSO in CASD with stiff or fused spines with a lower perioperative neurological injury profile. MOLIF have less SCM events, blood loss, and number of levels fused.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003034DOI Listing
August 2019

The role of cement augmentation with percutaneous vertebroplasty and balloon kyphoplasty for the treatment of vertebral compression fractures in multiple myeloma: a consensus statement from the International Myeloma Working Group (IMWG).

Blood Cancer J 2019 02 26;9(3):27. Epub 2019 Feb 26.

University of Athens School of Medicine, Athens, Greece.

Multiple myeloma (MM) represents approximately 15% of haematological malignancies and most of the patients present with bone involvement. Focal or diffuse spinal osteolysis may result in significant morbidity by causing painful progressive vertebral compression fractures (VCFs) and deformities. Advances in the systemic treatment of myeloma have achieved high response rates and prolonged the survival significantly. Early diagnosis and management of skeletal events contribute to improving the prognosis and quality of life of MM patients. The management of patients with significant pain due to VCFs in the acute phase is not standardised. While some patients are successfully treated conservatively, and pain relief is achieved within a few weeks, a large percentage has disabling pain and morbidity and hence they are considered for surgical intervention. Balloon kyphoplasty and percutaneous vertebroplasty are minimally invasive procedures which have been shown to relieve pain and restore function. Despite increasing positive evidence for the use of these procedures, the indications, timing, efficacy, safety and their role in the treatment algorithm of myeloma spinal disease are yet to be elucidated. This paper reports an update of the consensus statement from the International Myeloma Working Group on the role of cement augmentation in myeloma patients with VCFs.
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http://dx.doi.org/10.1038/s41408-019-0187-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391474PMC
February 2019

Symptom screening for constipation in oncology: getting to the bottom of the matter.

Support Care Cancer 2019 Jul 30;27(7):2463-2470. Epub 2018 Oct 30.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 16th Floor, Room 749, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.

Purpose: This study seeks to determine whether specific screening for constipation will increase the frequency of clinician response within the context of an established symptom screening program.

Methods: A "constipation" item was added to routine Edmonton Symptom Assessment System (ESAS) screening in gynecologic oncology clinics during a 7-week trial period, without additional constipation-specific training. Chart audits were then conducted to determine documentation of assessment and intervention for constipation in three groups of patients, those who completed (1) ESAS (n = 477), (2) ESAS-C with constipation (n = 435), and (3) no ESAS (n = 511).

Results: Among patients who were screened for constipation, 17% reported moderate to severe symptoms. Greater constipation severity increased the likelihood of documented assessment (Z = 2.37, p = .018) and intervention (Z = 1.99, p = .048). Overall rates of documented assessment were 36%, with the highest assessment rate in the no ESAS group (χ = 9.505, p = .006), a group with the highest proportion of late-stage disease. No difference in the rate of assessment was found between the ESAS and ESAS-C groups. Overall rates for documentation of intervention were low, and did not differ between groups.

Conclusions: Specific screening for constipation within an established screening program did not increase the documentation rate for constipation assessment or intervention. The inclusion of specific symptoms in multi-symptom screening initiatives should be carefully evaluated in terms of added value versus patient burden. Care pathways should include guidance on triaging results from multi-symptom screening, and clinicians should pay particular attention to patients who are missed from screening altogether, as they may be the most symptomatic group.
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http://dx.doi.org/10.1007/s00520-018-4520-7DOI Listing
July 2019

Managing the cervical spine in multiple myeloma patients.

Hematol Oncol 2019 Apr 15;37(2):129-135. Epub 2018 Nov 15.

Myeloma Spine Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

Discuss the relevant literature on surgical and nonsurgical treatments for multiple myeloma (MM) and their complementary effects on overall treatment. Existing surgical algorithms designed for neoplasia of the spine may not suit the management of spinal myeloma. Less than a fifth of metastatic, including myelomatous lesions, occur in the cervical spine but have a poorer prognosis and surgery in this area carries a higher morbidity. With the advances of chemotherapy, early access to radiotherapy, early orthosis management, and high definition imaging, including CT and MRI, surgical indications in MM have changed. Medical decompression (or oncolysis), including in the presence of neurological deficit and orthotic stabilization, are proving viable nonsurgical options to manage MM. A key to decision making is the assessment and monitoring of biomechanical spinal stability as part of a multidisciplinary approach.
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http://dx.doi.org/10.1002/hon.2564DOI Listing
April 2019

The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery.

Eur J Nucl Med Mol Imaging 2019 04 6;46(4):989-998. Epub 2018 Sep 6.

Institute of Nuclear Medicine, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK.

Purpose: Despite recent advances in lumbar spine stabilization surgery (LSSS), a high number of patients continue to complain of persistent/recurrent lumbar pain after LSSS. Conventional imaging (plain radiography, CT and MRI) is commonly performed to assess potential lumbar pain generators, but findings are equivocal in approximately 20% of patients. The purpose of this study was to assess the diagnostic performance of Tc-HDP bone SPECT/CT in identifying potential pain generators in patients with persistent/recurrent lumbar pain after LSSS but in whom conventional diagnostic imaging is inconclusive.

Methods: A total of 187 patients (median age 56 years, 70 men) with persistent/recurrent lumbar pain following LSSS with inconclusive conventional imaging (plain radiography, CT and/or MRI) underwent Tc-HDP bone SPECT/CT and were included in the study. Tracer uptake on SPECT/CT, as an indicator of ongoing or altered osteoblastic activity, was assessed in the lumbar spine stabilization segment(s) and in adjacent segments. Uptake intensity was graded as (1) high (the same as or more than iliac crest uptake), (2) mild (the same as or more than nondiseased vertebral uptake but less than iliac crest uptake), or (3) negative (normal scan). Mild and high uptake were regarded as positive.

Results: In 160 of the 187 patients (85.6%), SPECT/CT showed positive mild or high tracer uptake in the LSSS region. More than half of the patients had abnormal tracer uptake in the stabilized segments (56.7%) and/or in the adjacent segments (55.6%). Although positive stabilized segment findings were commonly seen at <2 years (70.3%) and the rate decreased with time after LSSS, they were seen at >6 years after surgery in 38.2% of patients. In 51.4% of patients, abnormal activity was seen in the adjacent segments <2 years after LSSS, suggesting early/accelerated degeneration after surgery. The proportion of patients with abnormal activity in the adjacent segments increased to 67.3% at >6 years after LSSS (p < 0.05). Positive SPECT/CT findings in the stabilized segments were more frequent in patients with three or more stabilized segments (p < 0.05), but were not more frequent in the adjacent segments. Overall, positive SPECT/CT guided therapy in 64% of patients, which included facet joint/nerve root injections or re-do surgery at active sites and/or adjacent sites.

Conclusion: Bone SPECT/CT is a sensitive diagnostic tool for identifying altered osteoblastic activity, which might be a pain generator in patients with persistent/recurrent pain after lumbar surgery especially when conventional imaging is inconclusive.
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http://dx.doi.org/10.1007/s00259-018-4141-xDOI Listing
April 2019

The evolution of partial undercutting facetectomy in the treatment of lumbar spinal stenosis.

J Spine Surg 2018 Jun;4(2):451-455

Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK.

Decompression of lumbar spinal stenosis is the most common spinal surgery in those over 60 years of age. While this procedure has shown immediate and durable benefits, improvements in outcome have not changed significantly. Technical aspects of surgical decompression have evolved significantly. The recently introduced ultrasonic bone cutter allows a precise and safe peri-neural bone resection. The principles of preservation of stability, as described by Getty have remained as relevant as when these were described 40 years ago.
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http://dx.doi.org/10.21037/jss.2018.06.06DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046331PMC
June 2018

Cancer Care Ontario's Systematic Symptom Screening Strategy: A Human-Centred Design Approach to Exploring System Gaps and Defining Strategies for the Future.

Healthc Q 2018 Jan;20(4):17-23

Director, Person-Centred Perspective at the Canadian Partnership Against Cancer Control. Prior to this, she was the provincial head, Nursing and Psychosocial Oncology at Cancer Care Ontario and involved in the Symptom Management Collaborative.

Cancer patients experience a high symptom burden throughout their illness. Quality cancer symptom management has been shown to improve patient quality of life and prevent emergency department use. Cancer Care Ontario introduced standardized symptom screening in Ontario, using the Edmonton Symptom Assessment System (ESAS) to facilitate patient reporting and management of symptoms. However, patient symptom information is not always sufficiently addressed. To address these gaps, patient and family advisors collaborated with clinicians, administrators and health system leaders from across the Province in a Symptom Management Summit to share perspectives and co-design context-specific solutions to improve care in their region.
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http://dx.doi.org/10.12927/hcq.2018.25428DOI Listing
January 2018

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

J Pediatr 2017 03 6;182:315-320.e1. Epub 2016 Dec 6.

The Royal National Orthopaedic Hospital, Stanmore, United Kingdom.

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.
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http://dx.doi.org/10.1016/j.jpeds.2016.11.031DOI Listing
March 2017

Reply to letter concerning "Segmental Pelvic Correlation (SPeC): a novel approach to understanding sagittal plane spinal alignment".

Spine J 2016 09;16(9):1159-60

Spinal Deformity Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.

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http://dx.doi.org/10.1016/j.spinee.2016.04.003DOI Listing
September 2016

Progressive foot drop caused by below-knee compression stocking after spinal surgery.

Oxf Med Case Reports 2016 Sep 8;2016(9):omw075. Epub 2016 Sep 8.

Spinal Deformity Unit , Department of Spinal Surgery , Royal National Orthopaedic Hospital ,  Stanmore , UK.

Foot drop is a debilitating condition, which may take many months to recover. The most common cause of foot drop is a neuropathy of the common peroneal nerve (CPN). However, similar symptoms can be caused by proximal lesions of the sciatic nerve, lumbar plexus or L5 nerve root. We present a rare and unusual case of a patient undergoing spinal surgery at the level of L5/S1 and presenting 4 weeks postoperatively with progressive foot drop. Although the initial concern was a postoperative lesion at L5, the cause for this delayed presentation was extrinsic compression of the CPN at the level of the fibular head by a tight-fitting below-knee thromboembolic deterrent stocking. Compression stockings are widely used in all branches of medicine and in the community. It is important to recognize this potential cause of progressive foot drop early as it is preventable by simple measures, which can significantly reduce morbidity.
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http://dx.doi.org/10.1093/omcr/omw075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015421PMC
September 2016

Spinal disease in myeloma: cohort analysis at a specialist spinal surgery centre indicates benefit of early surgical augmentation or bracing.

BMC Cancer 2016 07 11;16:444. Epub 2016 Jul 11.

Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.

Background: Multiple myeloma osteolytic disease affecting the spine results in vertebral compression fractures. These are painful, result in kyphosis, and impact respiratory function and quality of life. We explore the impact of time to presentation on the efficacy of spinal treatment modalities.

Methods: We retrospectively reviewed 183 patients with spinal myeloma presenting to our service over a 2 year period.

Results: Median time from multiple myeloma diagnosis to presentation at our centre was 195 days. Eighty-four patients (45.9 %) were treated with balloon kyphoplasty and the remainder with a thoracolumbar-sacral orthosis as per our published protocol. Patients presenting earlier than 195 days from diagnosis had significant improvements in patient reported outcome measures: EuroQol 5-Dimensions (p < 0.001), Oswestry Disability Index (p < 0.001), and Visual Analogue Pain Score (p < 0.001) at follow-up, regardless of treatment. Patients presenting after 195 days, however, only experienced benefit following balloon kyphoplasty, with no significant benefit from non-operative management.

Conclusion: Vertebral augmentation and thoracolumbar bracing improve patient reported outcome scores in patients with spinal myeloma. However, delay in treatment negatively impacts clinical outcome, particularly if managed non-operatively. It is important to screen and treat patients with MM and back pain early to prevent deformity and improve quality of life.
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http://dx.doi.org/10.1186/s12885-016-2495-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939590PMC
July 2016

A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes.

Spine J 2016 06 23;16(6):786-91. Epub 2016 Mar 23.

Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK; Department of Vascular Surgery, Royal Free London Hospital & University College London Hospital, Pond St, London, NW3 2QG, UK.

Background Context: A variety of surgical approaches have been used for cage insertion in lumbar interbody fusion surgery. The direct anterior approach requires mobilization of the great vessels to access the intervertebral disc spaces cranial to L5/S1. With the lateral retroperitoneal transpsoas approach, it is difficult to access the L4/L5 intervertebral disc space due to the lumbar plexus and iliac crest, and L5/S1 is inaccessible. We describe a new anterolateral retroperitoneal approach, which is safe and reproducible to access the disc spaces from L1 to S1 inclusive, obviating the need for a separate direct anterior approach to access L5/S1.

Purpose: This paper had the following objectives: first, to report a reproducible novel single-incision, muscle-splitting, anterolateral pre-psoas surgical approach to the lumbar spine from L1 to S1; second, to highlight the technical challenges of this approach and highlight approach-related complications; and third, to evaluate clinical outcomes using this surgical technique in a prospective series of L1 to S1 anterior lumbar interbody fusions (ALIFs) performed as part of a 360-degree fusion for adult spinal deformity correction.

Study Design: This report used a prospective cohort study.

Patient Sample: A prospective series of patients (n=64) having ALIF using porous tantalum cages as part of a two-stage complex spinal reconstruction from L1 to S1 were studied.

Outcome Measures: Data collected included blood loss, operative time, incision size, technical challenges, perioperative complications, and secondary procedures. Clinical outcome measures used included visual analogue scale (VAS) Back Pain, VAS Leg Pain, EuroQoL-5 Dimensions (EQ-5D), EQ-5D VAS, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22).

Methods: Pre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 1.8 years.

Results: Mean blood loss was 68±9.6 mL. The mean VAS Back Pain score improved from 7.5±1.25 preoperatively to 2.5±1.7 at 3 months (p=.02), 1.2±0.5 at 6 months (p=.01), and 1.4±0.6 at 1 year (p=.02). The mean ODI improved from 64.3±31.8 preoperatively to 16.6±14.7 at 3 months (p>.05), 10.7±6.0 at 6 months (p=.02), and 6.7±6.1 at 1 year (p=.01). There were no permanent neurologic, vascular, or visceral injuries. One revision anterior procedure was required on a patient with rheumatoid arthritis and advanced systemic disease that sustained a sacral fracture and required revision ALIF at L5/S1.

Conclusions: The technique described is a safe, new, muscle-splitting, psoas-preserving, one-incision approach to provide access from L1 to S1 for multilevel anterior or oblique lumbar interbody fusion surgery.
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http://dx.doi.org/10.1016/j.spinee.2016.03.044DOI Listing
June 2016

Multiple myeloma presenting with acute bony spinal cord compression and mechanical instability successfully managed nonoperatively.

Spine J 2016 08 17;16(8):e567-70. Epub 2016 Mar 17.

Spinal Deformities Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK.

Background Context: Multiple myeloma (MM) with spinal involvement may present with spinal cord or cauda equina compression, with or without neurological impairment. This occurs when a soft-tissue myelomatous mass extends into the epidural space (Barron et al., 1959 [1]). The mainstay of management for such lesions in patients with normal neurology is chemotherapy and radiotherapy or radiotherapy alone, but those with neurological compromise require surgical decompression with adjuvant therapy (Patchell et al., 2005 [2]). Infrequently, patients with MM present with spinal cord compression and neurological impairment due to bony encroachment from vertebral translation and kyphosis where significant lytic bone disease has rendered the spine mechanically unstable. The standard management for these patients is surgical decompression and internal fixation.

Purpose: This study aimed to report a high-risk myeloma patient with a mechanically unstable spine, acute spinal cord compression, and neurologic deficit that was treated successfully using nonoperative means.

Study Design: Case report.

Methods: A 37-year-old male patient with MM was referred to our tertiary referral spinal unit with acute bony spinal cord compression and neurological impairment. Computer tomography revealed lytic lesions of T2 and T3 and anterolisthesis of T1 on T2 producing mechanical instability and magnetic resonance imaging confirmed extension of disease into the epidural space and cord compression. This was successfully managed with nonoperative treatment using a brace.

Results: Management in a brace restored clinical and radiological stability and normal neurological function.

Conclusion: Certain high-risk myeloma patients with a mechanically unstable spine, acute spinal cord compression and neurologic deficit can be treated effectively in an appropriate brace when managed by a tertiary referral spinal unit.
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http://dx.doi.org/10.1016/j.spinee.2016.03.011DOI Listing
August 2016

Is balloon kyphoplasty safe and effective for cancer-related vertebral compression fractures with posterior vertebral body wall defects?

J Surg Oncol 2016 Jun 21;113(7):835-42. Epub 2016 Mar 21.

University College London Hospital, London, United Kingdom.

Background And Objectives: Balloon kyphoplasty (BKP) is a percutaneous treatment for cancer-related vertebral compression fractures (VCF). Posterior vertebral body wall (PVBW) involvement is considered a contraindication for BKP. This study assesses whether BKP is safe and effective for cancer-related VCFs involving the PVBW.

Methods: This study analyzed data on 158 patients with 228 cancer-related VCFs who underwent BKP. One hundred and twelve patients had VCFs with PVBW defects, and 46 had VCFs with no PVBW defect. Outcomes were assessed preoperatively and at 3 months.

Results: In the PVBW defect group, mean pain score decreased from 7.5 to 3.6 (P < 0.001), EQ5D increased from 0.39 to 0.48 and Oswestry Disability Index (ODI) decreased from 50 to 42. Cement leaks occurred in 31%. In the PVBW intact group, mean pain decreased from 7.3 to 3.3 (P < 0.001), EQ5D increased from 0.35 to 0.48 (P < 0.001), and ODI decreased from 53 to 50. Cement leaks occurred in 20%. No significant difference was observed in functional improvements between groups. Radiographically kyphotic angle and anterior and middle vertebral body heights were significantly worse in the PVBW defect group (P < 0.05).

Conclusions: BKP can alleviate pain and improve QoL and function in patients with cancer-related VCFs with PVBW defects with no appreciable increase in risk. J. Surg. Oncol. 2016;113:835-842. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24222DOI Listing
June 2016

Successful nonsurgical treatment for highly unstable fracture subluxation of the spine secondary to myeloma.

Spine J 2016 08 9;16(8):e547-51. Epub 2016 Mar 9.

Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.

Background Context: In multiple myeloma, patients may develop rapidly progressive, lytic, spinal lesions. These may result in spinal instability, but instrumented stabilization may fail because of poor bone quality. In addition, patients are immunocompromised and are therefore at increased risk of deep infection.

Purpose: The aim was to describe a patient presenting with an unstable fracture subluxation of the thoracic spine secondary to myeloma, successfully treated with non-surgical management.

Study Design/setting: This is a case report of a patient seen in a specialist spinal myeloma service.

Methods: A 74-year-old Caucasian woman presented with destructive myelomatous lesions of T9 and T10. Greater than 50% of the T9 vertebral body was involved, and there was subluxation and translation of T9 on T10 (Spinal Instability Neoplastic Score of 14). There was a single episode of transient paresthesia of both lower limbs. The patient was in considerable pain, requiring large quantities of opioid analgesia. She was treated non-surgically in a thoracolumbar sacral orthosis for a period of 3 months (strict bed rest for the first 3 weeks).

Results: A computed tomography scan at 3 months demonstrated bony fusion and the brace was removed. The patient returned to her normal activities 5 months posttreatment. Her pain and patient-reported outcome scores were significantly improved.

Conclusions: We present a successful non-surgical management of an unstable myelomatous vertebral fracture without neurologic deficit. However, surgical stabilization remains the treatment of choice in unstable vertebral fractures and spinal surgical opinion should be sought in all cases.
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http://dx.doi.org/10.1016/j.spinee.2016.03.008DOI Listing
August 2016

Cancer Care Professionals' Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada.

J Pain Symptom Manage 2016 Apr 30;51(4):662-672.e8. Epub 2015 Dec 30.

University of Ottawa, Ottawa, Ontario, Canada.

Context: Cancer patients experience a high symptom burden throughout their illness. Despite this, patients' symptoms and needs are often not adequately screened for, assessed, and managed.

Objectives: This study investigated the attitudes of cancer care professionals toward standardized systematic symptom assessment and the Edmonton Symptom Assessment System (ESAS) and their self-reported use of the instrument in daily practice in a large healthcare jurisdiction where this is routine.

Methods: A 21-item electronic survey, eliciting both closed and open-ended anonymous responses, was distributed to all 2806 cancer care professionals from four major provider groups: physicians, nurses, radiotherapists, and psychosocial oncology (PSO) staff at the 14 Regional Cancer Centres across Ontario, Canada.

Results: A total of 1065 questionnaires were returned (response rate: 38%); 960 were eligible for analysis. Most respondents (88%) considered symptom management to be within their scope of practice. Sixty-six percent of physicians considered the use of standardized tools to screen for symptoms as "best practice," compared to 81% and 93% of nurses and PSO staff, respectively. Sixty-seven percent of physicians and 85% of nurses found the ESAS to be a useful starting point to assess patients' symptoms. Seventy-nine percent of physicians looked at their patient's ESAS scores at visits either "always" or "often," compared to 29%, 66%, and 89% of radiotherapists, PSO staff, and nurses, respectively. Several areas for improvement of ESAS use and symptom screening were identified.

Conclusion: Findings show significant albeit variable uptake across disciplines in the use of the ESAS since program initiation. Several barriers to using the ESAS in daily practice were identified. These need to be addressed.
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http://dx.doi.org/10.1016/j.jpainsymman.2015.11.023DOI Listing
April 2016

Review article: Surgical approaches for correction of post-tubercular kyphosis.

J Orthop Surg (Hong Kong) 2015 Dec;23(3):391-4

The Johns Hopkins Hospital, United States.

This study reviewed the literature regarding the pros and cons of various surgical approaches (anterior, anterolateral, combined, and posterior) for correction of post-tubercular kyphosis. The anterior and anterolateral approaches are effective in improving neurological deficit but not in correcting kyphosis. The combined anterior and posterior approach and the posterior approach combined with 3-column osteotomy achieve good neurological improvement and kyphosis correction. The latter is superior when expertise and facilities are available.
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http://dx.doi.org/10.1177/230949901502300328DOI Listing
December 2015

Does Spinal Fusion and Scoliosis Correction Improve Activity and Participation for Children With GMFCS level 4 and 5 Cerebral Palsy?

Medicine (Baltimore) 2015 Dec;94(49):e1907

From the Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK.

Spinal fusion is used to treat scoliosis in children with cerebral palsy (CP). Following intervention, the WHO considers activity and participation should be assessed to guide intervention and assess the effects. This study assesses whether spinal fusion for scoliosis improves activity and participation for children with severe CP.Retrospective cohort study of 70 children (39M:31F) with GMFCS level 4/5 CP and significant scoliosis. Thirty-six underwent observational and/or brace treatment as the sole treatment for their scoliosis, and 34 underwent surgery. Children in the operative group were older and had worse scoliosis than those in the observational group. Questionnaire and radiographic data were recorded over a 2-year period. The ASKp was used to measure activity and participation.In the observational group, Cobb angle and pelvic obliquity increased from 51 (40-90) and 10 (0-30) to 70 (43-111) and 14 (0-37). Mean ASKp decreased from 16.3 (1-38) to 14.2 (1-36). In the operative group, Cobb angle and pelvic obliquity decreased from 81 (50-131) and 14 (1-35) to 38 (10-76) and 9 (0-24). Mean ASKp increased from 10.5 (0-29) to 15.9 (3-38). Spinal-related pain correlated most with change in activity and participation in both groups. There was no difference in mobility, GMFCS level, feeding or communication in either group before and after treatment.In children with significant scoliosis and CP classified within GMFCS levels 4 and 5, spinal fusion was associated with an improvement in activity and participation, whereas nonoperative treatment was associated with a small reduction. Pain should be carefully assessed to guide intervention.
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http://dx.doi.org/10.1097/MD.0000000000001907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008467PMC
December 2015

Pathologic sternal involvement is a potential risk factor for severe sagittal plane deformity in multiple myeloma with concomitant thoracic fractures.

Spine J 2015 Dec 25;15(12):2503-8. Epub 2015 Sep 25.

Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

Background Context: Skeletal involvement is observed in almost 80% of patients presenting with symptomatic multiple myeloma (MM). The vertebral column is the most frequently affected site by myeloma-induced osteoporosis, osteolysis, and compression fractures. Multiple pathologic compression fractures can lead to significant spinal deformity, which is often considered for complex reconstruction because of the poor quality of life for the affected patients.

Purpose: This study aimed to compare the clinical and radiological outcomes of two groups of MM patients; the first group had thoracic spine fractures and a concomitant pathologic sternal fracture (SF), and the second group had thoracic fractures but no sternal fracture (NSF).

Study Design: This was a cross-sectional study.

Patient Sample: The sample comprised 98 consecutive patients (n=98) with symptomatic MM and concomitant pathologic thoracic spine fractures over a 3-year period at a national tertiary referral center for the management of MM with spinal involvement.

Outcome Measures: Clinical outcome measures used included European Quality of Life-5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), and visual analogue scale (VAS) pain score.

Methods: All consecutive patients with MM were enrolled. The cohort was split into two patient groups: patients with SFs (SF group) and patients without sternal fractures (NSF group). Clinical, serologic, and pathologic variables, radiological findings, treatment strategies, and outcome measures were collected.

Results: The SF group was younger (58±13 years vs. 66±11 years [p=.008]) when compared with the NSF group. The SF group presented with a greater thoracic kyphosis (73°±18° vs. 53°±17.5° [p=.005]), similar VAS pain scores (50.6±22.1 vs. 54.4±22.5 [p>.05]), but poorer EQ-5D (0.24±0.13 vs. 0.48±0.23 [p<.001]) score and ODI (60.6±10.3 vs. 48.2±17.8 [p=.013]) when compared with the NSF group.

Conclusions: Pathologic SF in an MM patient with thoracic compression fractures is a potential risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated in this study to be associated with a very poor health-related quality of life. A greater awareness of sternal myeloma disease is needed at presentation (the time of the primary survey) so that SFs can be potentially avoided, thereby preventing progression to a severe kyphotic deformity.
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http://dx.doi.org/10.1016/j.spinee.2015.09.031DOI Listing
December 2015

Segmental Pelvic Correlation (SPeC): a novel approach to understanding sagittal plane spinal alignment.

Spine J 2015 Dec 25;15(12):2518-23. Epub 2015 Sep 25.

Spinal Deformity Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.

Background Context: Lumbar lordosis (LL) correlates with pelvic morphology, and it has been demonstrated that as LL increases, the inflection point and apex of lordosis move cranially. This suggests that each segment of the lumbar spine relates to pelvic morphology in a unique way.

Objectives: This study aimed to establish whether there is a direct relationship between pelvic morphology and lumbar segmental angulation in the sagittal plane.

Study Design: A retrospective analysis of 41 patient radiographs was carried out.

Patient Sample: Inclusion criteria included patients with full length standing anterioposterior and lateral radiographs of the spine from base of occiput to proximal femora, with clearly visible vertebral end plates from T12 to S1 and a thoracic kyphosis (TK) and LL within the normal range. Patients were excluded if they had a coronal spinal deformity affecting the lumbar spine, chronic back pain, spondylolisthesis, spondylolysis, congenital scoliosis, or skeletal dysplasia.

Outcome Measures: Spinopelvic radiographic parameters of pelvic incidence (PI), LL, TK, and segmental angulation at each level from L1 to the sacrum were the outcome measures.

Methods: Forty-one lateral whole spine radiographs with normal sagittal profiles from the spinal deformity clinic were retrospectively reviewed. Pelvic incidence, LL, TK, and segmental angulation at each level from L1 to the sacrum were measured (from end plate to end plate), distinguishing the vertebral body and intervertebral disc contribution. Pearson correlation coefficients were used to analyze any relationship between pelvic parameters and segmental angulation.

Results: A strong correlation was found between PI and LL. Pelvic incidence correlated strongly with the L1 and L2 motion segments (p=.0001, p=.03), notably at the intervertebral discs but not the L4 and L5 motion segments. The proportion of total LL contributed at L4-L5 and L5-S1 reduced as PI increased.

Conclusions: Pelvic incidence can predict segmental angulation. Although the majority of LL is produced at the L4 and L5 motion segments, cephalad lumbar segments sequentially become increasingly important as PI increases. This describes a continuum where the L1 and L2 motion segments crucially fine-tune total LL according to PI. This allows segmental abnormalities to be identified when compensation in adjacent segments maintain normal total LL. It also paves the way for anatomical segmental reconstruction in degenerative adult deformity based on pelvic morphology.
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http://dx.doi.org/10.1016/j.spinee.2015.09.021DOI Listing
December 2015

Optimizing the management of patients with spinal myeloma disease.

Br J Haematol 2015 Nov 17;171(3):332-43. Epub 2015 Jul 17.

Department of Haematology, Northwick Park Hospital and Department of Haematology and Stem Cell Transplantation, Royal Free Hospital, London, UK.

Myeloma is one of the most common malignancies that results in osteolytic lesions of the spine. Complications, including pathological fractures of the vertebrae and spinal cord compression, may cause severe pain, deformity and neurological sequelae. They may also have significant consequences for quality of life and prognosis for patients. For patients with known or newly diagnosed myeloma presenting with persistent back or radicular pain/weakness, early diagnosis of spinal myeloma disease is therefore essential to treat and prevent further deterioration. Magnetic resonance imaging is the initial imaging modality of choice for the evaluation of spinal disease. Treatment of the underlying malignancy with systemic chemotherapy together with supportive bisphosphonate treatment reduces further vertebral damage. Additional interventions such as cement augmentation, radiotherapy, or surgery are often necessary to prevent, treat and control spinal complications. However, optimal management is dependent on the individual nature of the spinal involvement and requires careful assessment and appropriate intervention throughout. This article reviews the treatment and management options for spinal myeloma disease and highlights the value of defined pathways to enable the proper management of patients affected by it.
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http://dx.doi.org/10.1111/bjh.13577DOI Listing
November 2015

A multicentre retrospective review of muscle necrosis of the leg following spinal surgery with motor evoked potential monitoring: a cause for concern?

Eur Spine J 2016 Mar 11;25(3):801-6. Epub 2015 Jun 11.

Spinal Deformity Unit, Royal National Orthopaedic Hospital (RNOH), Brockley Hill, Stanmore, HA7 4LP, Middlesex, UK.

Purpose: There are very few reported cases of compartment syndrome of the leg following spinal surgery via a posterior approach. An association between compartment syndrome and muscle over-activity via nerve stimulation during evoked potential monitoring was first suggested in 2003. No further reports have suggested this link. We present a multicentre retrospective review of a series of five patients who developed compartment syndrome of the leg following spinal surgery via a posterior approach, whilst un-paralysed and with combined sensory (SSEP)/motor evoked potential (MEP) monitoring with an aim of highlighting this possible causative factor.

Methods: All data were 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. Finally, the literature was reviewed.

Results: All patients were operated on by three different surgeons, on different operating tables/mattresses in the prone position. The common factors were un-paralysed patients having motor/sensory monitoring, mechanical calf pumps and total intravenous anaesthesia. Three patients underwent surgical decompression of their compartments and two were treated expectantly. Three patients had confirmed intra-compartmental changes on MRI consistent with compartment syndrome and one had intra-compartmental pressure monitoring which confirmed the diagnosis.

Conclusions: Previous cases in the literature have related to mal-positioning on the Jackson table or use of the knee-chest position for surgery. This was not the case for our patients; therefore, we suspect an association between overactive muscle stimulation and muscle necrosis. Further experimental studies investigating this link are required.
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http://dx.doi.org/10.1007/s00586-015-4063-2DOI Listing
March 2016

Spinal fusion from nonoperative management of lytic myelomatous vertebrae.

Spine J 2019 02 30;19(2):e4-e5. Epub 2015 Apr 30.

Spinal Deformities Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.

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http://dx.doi.org/10.1016/j.spinee.2015.04.034DOI Listing
February 2019

A Preliminary Study to Assess Whether Spinal Fusion for Scoliosis Improves Carer-assessed Quality of Life for Children With GMFCS Level IV or V Cerebral Palsy.

J Pediatr Orthop 2016 Apr-May;36(3):299-304

The Royal National Orthopaedic Hospital, Stanmore, London, UK.

Background: Scoliosis affects 50% of children with Gross Motor Function Classification System (GMFCS) level IV or V cerebral palsy (CP). In children with complex neurodisability following intervention, the WHO considers quality of life (QoL) should be assessed to aid decision-making and assess the effects. This study assesses whether scoliosis surgery improves carer-assessed QoL for children with severe CP.

Methods: Retrospective review of 33 children (16 male:17 female) with GMFCS level IV/V CP and significant scoliosis. Fifteen underwent observational treatment during childhood, and 18 underwent surgery. Questionnaire and radiographic data were recorded over a 2-year period. The carer-completed Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was used to assess QoL.

Results: In the observational group, Cobb angle and pelvic obliquity increased from 46 (40 to 60) and 8 degrees (0 to 28) to 62 (42 to 94) and 12 degrees (1 to 35). Mean CPCHILD score decreased from 50 (30 to 69) to 48 (27 to 69) (P<0.05). In the operative group, Cobb angle and pelvic obliquity decreased from 78 (52 to 125) and 14 degrees (1 to 35) to 44 (16 to 76) and 9 degrees (1 to 24). Mean CPCHILD score increased from 45 (20 to 60) to 58 (37 to 76) (P<0.05). Change in pain, and not presence of associated impairments, was the most significant factor affecting QoL changes for children in both groups. There was no difference in mobility, GMFCS level, feeding, or communication in either group before and after treatment.

Conclusions: Nonoperative treatment for children with GMFCS level IV/V CP and a significant scoliosis was associated with a small decrease in carer-assessed QoL over 2 years. Spinal fusion was associated with an increase in QoL. Change in pain was the most significant factor affecting QoL changes, and is therefore an important factor to consider when deciding upon surgery.

Level Of Evidence: Level III-therapeutic retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000000447DOI Listing
November 2016

The utility of single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging in the diagnosis of a vertebral compression fracture in multiple myeloma.

Spine J 2015 Jul 7;15(7):1682-3. Epub 2015 Feb 7.

Myeloma Spinal Service, Department of Spinal Surgery, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK.

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http://dx.doi.org/10.1016/j.spinee.2015.02.008DOI Listing
July 2015
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