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30
DEC
2012

THE USE OF EXPANDABLE CAGES AND VENTROLATERAL LOCKING PLATES IN SEVERE SPINAL INFECTIONS

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THE USE OF EXPANDABLE CAGES AND VENTROLATERAL LOCKING PLATES IN SEVERE SPINAL INFECTIONS

Meir AR, Hamady M, Akmal M

ST MARYS HOSPITAL,IMPERIALCOLLEGEHEALTHCARE NHS TRUST

 Introduction

Spinal infections are a significant cause of morbidity and mortality in both the developed and developing world. Epidemiological data suggests the incidence of pyogenic and mycobacterial infections is increasing in European countries. Less severe cases can be managed with antibiotics, bracing and careful observation. In severe infections, with neurological deficit, progressive deformity or uncontrolled sepsis, the mainstay of surgical management is debridement with or without stabilisation using anterior and posterior instrumentation. Recent developments in spinal instrumentation include in situ expandable cages and ventrolateral locking plates.  We have used a construct consisting of an anterior expandable cage with a ventrolateral locking plate in destructive spinal infections.

 Method

14 Patients who had undergone surgical intervention for spinal infection were reviewed retrospectively for upto 2 years. Complications, post op systemic and neurological status were assessed. In those cases where a cage/ plate construct was used from an isolated anterior approach, post operative radiographs were analysed for implant stability, deformity correction and radiological fusion.

 Results

Good early results in terms of safety, resolution of pain, control of deformity and improvement of neurological deficits have been observed. Post operative radiological assessment showed the cages to be stable with time and further deformity progression was prevented. In one case of an elderly patient, vertebral body cement augmentation was required to prevent subsidence. There have been no cases of implant displacement or loosening.

 Conclusion

Expandable cages with ventrolateral locking plates appear to provide satisfactory stable fixation from an isolated anterior approach in severe spinal infections. We have found the technique safe and have shown good short term results both clinically and radiologically. Further studies are required to show long term efficacy.

30
DEC
2012

Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer

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Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer
Aneel Bhangu1,2, Gina Brown3, Mohammed Akmal1,4, Paris Tekkis1,2

1. Department of Colorectal Surgery, The Royal Marsden Hospital, Fulham Road, London
2. Division of Surgery, Imperial College, Chelsea and Westminster Campus, London
3. Department of Radiology, the Royal Marsden Hospital, Fulham Road, London
4. Department of Orthopaedic and Trauma Surgery, Imperial College NHS Trust, London

Article type: Original article
Conflict of interest: none
Word count: 3792
Abstract: 250
Keywords: sacrectomy; abdominosacral resection; recurrent rectal cancer; locally advanced rectal cancer; exenteration

Funding: The present study is funded by the Imperial College Cancer Research UK centre.

Abstract
Aim: To assess the indications and outcomes of abdominosacral resection for patients with locally advanced primary and recurrent rectal cancer.
Methods: Consecutive patients undergoing abdominosacral resection between January 2006 and December 2011 were identified from a prospectively maintained database. The main endpoint was 3-year local recurrence-free (LRFS).
Results: Thirty patients underwent abdominosacral resection, 22 for recurrent rectal cancer and 8 for locally advanced primary cancer. Sacrectomy was performed at S1/S2 in 5, at S3 in 11 and at S4/S5 in 14 patients. R0 resection was achieved in 23 patients, with seven R1 resections; all positive margins were in patients with recurrent disease. There were no 30-day/in-hospital mortalities. S1/S2 sacrectomy was associated with the highest rate of major complications compared to S3 or S4/S5 sacrectomy (60, 30 and 40 per cent respectively) and long-term complications (60, 36, 14 per cent respectively). Overall 3-year LRFS was 66 per cent and 3-year disease free (DFS) survival was 55 per cent. These were both significantly improved with negative versus positive margins (LRFS 87 per cent versus 0 per cent [p<0.001] and DFS 71 per cent versus 0 per cent respectively [p=0.032]).
Conclusions: Abdominosacral resection can lead to long-term survival for patients with advanced rectal cancer where carefully selected. Post-operative complications are common and often multiple. Sacrectomy for locally advanced primary rectal cancer was associated with a low margin positive rate and should be considered as an acceptable treatment. Margin positive resection was associated with poor survival outcomes and should be avoided.

30
DEC
2012

Spinal Multi Disciplinary Service and Electronic Patients Record- Room for improvement.

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Spinal Multi Disciplinary Service and Electronic Patients Record- Room for improvement.

 A Hussien, B Obaidi, R Mobashari, Mo Akmal,

Imperial College NHS Trust, St Mary’s Hospital, London, UK

 Introduction

St Mary’s Hospital (part of Imperial College NHS Trust) inLondon, became an adult Major Trauma Centre (MTC) in January 2011. Prior to that, there was no neurosurgical service on site and only a tertiary referral service for orthopaedic spinal surgery was available.  The increase in workload necessitated joint working patterns and improvement in communication between subspecialist teams.

 Methods

Two dedicated MDT sessions per week for spinal trauma cases and elective referrals, Joint OPD clinics and shared access to spinal theatre sessions were implemented. The Radiology PACS system, E-Trauma system, web based spinal database and a separate computerised ITU system are currently in use. The trust have agreed to become part of the first wave of NHS hospitals employing a fully computerised medical record system ie Cerner.

 Results

MDT meetings are attended by Orthopaedic spinal surgeons, spinal Neurosurgeons, Rheumatologist, Therapists, pain team, consultant radiologists, spinal fellows and SpRs. The Electronic records for the MDT meetings started in 2010, 1348 elective referral cases were discussed. These comprised mainly of back pain, sciatica and other non emergency cases. 35% were discharged, 65% seen in clinic to discuss surgical treatment.  A total of 295 emergency cases were also discussed. There was a variable use and compliance with Electronic patients records.

 Conclusions

The creation of new MTC’s in the UK will lead to concentration of spinal emergency and complex spinal surgery to a few specialised centres. A combination of neurosurgical and orthopaedic skills are often required. Spinal MDT’s are an excellent way to facilitate communication and agree treatment plans. Senior consultant input is required to guide juniors, avoid unnecessary costs and delays, provide a governance framework and discuss treatment options .

26
DEC
2012

Spinal Injuries in the First Year of a Major Trauma Centre in the UK

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Spinal Injuries in the First Year of a Major Trauma Centre in the UK
A M Hussien,  L Yuinchung, , N Patrick, M Wilson, M Akmal
Imperial College NHS Trust, St Mary’s Hospital, London, UK
Aim: 
St Mary’s Hospital (part of Imperial College NHS Trust) in London, became an adult Major Trauma Centre (MTC) in January 2011. Prior to that, there was no neurosurgical service on site and only a tertiary referral service for orthopaedic spinal surgery was available. We reviewed the demographics, mechanisms, injury site, and associated injuries of all spinal trauma patients admitted via the MTC and also report on the challenges encountered in providing a specialist spinal trauma service in a newly designated MTC.
Methods:
A retrospective review of all admissions to the MTC was performed and patients with spinal injuries were selected for detailed analysis. Difficulties encountered in delivering optimal care i.e. staffing availability, nurse training, physiotherapy expertise, theatre availability, implants and logistical problems were categorised. Summary of the solutions devised is also reported.
Results:
In 2011, the service received 1807 Trauma Calls of which 201 spinal patients (66 were female, 135 male), age (4-95) average 53; mean 38 due to RTA, 87 due to falls (some under the influence of alcohol), and 76  had other injuries and pathology. 71 had cervical spine pathology (9 combined cervical and thoracic injuries), 36 had thoracic pathology (2 combined thoracic and lumbar injuries), 89 had lumbar pathology, 1 sacral and 3 normal. 11 had more than one location of fractures. 76 had various surgical and radiological interventions. Other injuries include 702 with head injury. A total of 79 pediatric cases were admitted to hospital. 32 children with head injuries and 3 with spinal injuries.

The service demanded a higher spinal surgical input than was expected and new arrangements were established between orthopaedic and neurosurgical services. Communication difficulties were resolved with twice weekly MDT meetings and the use of a computerised and networked patient trauma software (etrauma). A designated weekly spinal trauma list with the availability of extra theatre slots during the week was created. Senior consultants  input was required to avoid unnecessary use of MRI imaging, spinal braces, bed days and surgical complications. A core spinal team was created and all patients were handed over during working hours to maintain a continuity of care. Spinal rehabilitation created challenges related to clinical management, bed numbers and onward referral to spinal injury centres
Conclusions:
The creation of new MTC’s in the UK will lead to concentration of spinal trauma surgery to a few specialised centres. The complexity of surgery requires a combination of neurosurgical and orthopaedic skills. Senior consultant input is required at the early phase and clear protocols, communication through MDT’s and junior team infrastructure are essential to avoid unnecessary costs and delays to treatment. Lack of training amongst nurses and physiotherapists needs to be addressed by extra staff with a specialist interest. A regular designated spinal trauma list ensures appropriate theatre staff and equipment availability for surgery. A patient tracking system is essential to keep a record of all inpatients and referrals from a variety of sources.