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Peter Millner

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Papers by Peter Millner

The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis, treatment and therapeutic outcomes

European Spine Journal, Apr 1, 2013

Purpose The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) ... more Purpose The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) is increasing. We performed a retrospective cohort study of patients with this type of infection in an effort to gain an improved understanding of the current clinical presentation, management and outcome. Methods Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from GNB HVO were identified and their microbiological diagnoses were evaluated. Results This study identified seventy-nine patients with haematogenous vertebral osteomyelitis (HVO). Of these seventy-nine patients, 10 patients (12.66 %) had Gramnegative organisms isolated. These organisms included Escherichia coli (4), Pseudomonas aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Eight patients were successfully treated with antibiotics and/or surgery. Of the eight patients whose HVO was cured, five had Ciprofloxacin as part of their definitive antibiotic regime. Conclusion The treatment of GNB HVO is often challenging because of unpredictable resistance patterns and limited published data on effective treatment regimens. Our study has highlighted the need for prompt microbiological sampling and initiation of early appropriate antibiotic regime. The most effective treatment for GNB HVO was with oral Ciprofloxacin over a period of 6-8 weeks.

$Research paper thumbnail of Spine fractures$

Spine fractures

The Incidence of Gram-Negative Haematogenous Vertebral Osteomyelitis in a Tertiary Referral Spinal Unit

Orthopaedic Proceedings, Jun 1, 2012

Purpose of study The aim of this study was to identify the incidence of Gram negative bacterial v... more Purpose of study The aim of this study was to identify the incidence of Gram negative bacterial vertebral osteomyelitis (VO) within our unit during a 3-year study period and evaluate if this corresponds to published evidence that the occurrence is increasing. Methods Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from Gram-negative VO were identified and their microbiological diagnoses were evaluated. All patients were treated within a large tertiary spinal surgery unit in Leeds. Results This study identified 79 patients with haematogenous VO. Of these 79 patients, 10 patients (12.66%) had Gram-negative organisms isolated. These organisms included E. Coli (4), Pseudomonal aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Four patients had the causative organism isolated on =2 positive blood cultures, three from biopsy and =2 positive blood culture, one from biopsy alone and two were diagnosed from 1 positive blood culture. Conclusion VO is a common manifestation of osteomyelitis in adults, representing 2-7% of all cases of osteomyelitis. Staphylococcus aureus is the most common causative aetiological agent in haematogenous spinal infections, accounting for between 40 - 60% of cases. Despite the fact that Gram negative bacteria infections represent a minor proportion of all cases of VO, around 15 - 23%, recent evidence suggests that the microbiology of this disease may be changing and the incidence of Gram-negative bacterial infections are increasing. This has been attributed a variety of factors including, an increasing proportion of individuals with predisposing risk factors such as advanced age, diabetes mellitus, malignancy and better diagnostic techniques. Results from our study show an incidence of Gram-negative VO of 12%, which is less than results quoted in the literature and does not confirm recent evidence that these types of spinal infections are increasing in incidence.

Peter Alexander Templeton

BMJ, May 2, 2012

Peter Alexander Templeton was born and grew up in Canada, where his father, also an orthopaedic s... more

Translaminar screw fixation of a kyphosis of the cervical and thoracic spine in neurofibromatosis

The journal of bone and joint surgery, Sep 1, 2009

Case report 745

Skeletal Radiology, Aug 1, 1992

Examination of the spine in childhood

Cambridge University Press eBooks, Jun 9, 2014

Late-Onset Idiopathic Scoliosis in Children Six to Fourteen Years Old. A Cross-Sectional Prevalence Study

Journal of Pediatric Orthopaedics, Mar 1, 1997

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed ... more We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Spinal injuries affecting the lumbosacral spine and pelvis

Orthopaedics and Trauma, Oct 1, 2016

Lumbo-sacral fractures are complex injuries that often occur alongside pelvic ring trauma. They a... more Lumbo-sacral fractures are complex injuries that often occur alongside pelvic ring trauma. They are often missed on initial assessment and plain radiography, and delayed treatment can lead to pain, reduced mobility and neurological compromise. Careful clinical examination is essential and identification of the fracture pattern often requires CT imaging. A large number of classification systems are available to help guide decision-making and these have recently been summarised in the comprehensive AO Spine sacral fracture classification system. Surgical intervention includes both neurological decompression and stabilisation and is indicated for patients with neurological compromise, lumbo-sacral instability and significant soft tissue injuries.

Estimated cumulative X-ray exposure and additional cancer risk during the evaluation and treatment of scoliosis in children and young people requiring surgery

Spine deformity, Mar 3, 2021

Introduction Clinicians and patients must weigh the benefits of radiological imaging against the ... more Introduction Clinicians and patients must weigh the benefits of radiological imaging against the risks of radiation exposure in the diagnosis and treatment of scoliosis. This report aims to estimate the cumulative absorbed and equivalent dose of radiation in patients undergoing surgical treatment for scoliosis, and to present this as an estimated risk of cancer compared to background radiation levels. Methods Retrospective review of estimated absorbed dose on the Computerised Radiology Information System (CRIS ®). Patients undergoing surgical correction of scoliosis (age ≤ 25) from August 2010 to August 2015 investigated. Estimated absorbed dose [milligrays (mGy)] recorded. Pedicle screws inserted using image intensification. Equivalent dose [millisieverts (mSv)] and additional cancer risk calculated from the National Research Council document 'Health risks from exposure to low levels of ionising radiation' (2006). Results 271 patients identified. Mean age 15 (range 2-25). Mean total absorbed dose 2136 mGy [standard deviation (SD) 1700 mGy]. Mean number of plain spine radiographs was 8 (SD 3) with total 1884 mGy exposure (SD 1609 mGy). Additional dose provided by CT (mean 0.17 episodes), plain chest and abdominal radiographs and image intensification. Mean number of image intensification episodes was 1.1 with mean estimated exposure 180 mGy (SD 238 mGy). Image intensification accounted for 8% of the estimated absorbed dose during treatment. Estimated mean effective dose delivered was 20.952 mSv equating to an additional cancer risk of 0.27-0.45%. Conclusion Additional cancer risk from cumulative imaging is small and equivalent to approximately 8 years of natural background radiation. Use of image intensification for pedicle screw insertion is a minor contribution (8%) to the total patient dose.

A study of three-dimensional curves

Journal of Applied Statistics, Feb 1, 1996

In certain abnormalities of spinal shape, the long axis of the spine moves out of the median sagi... more In certain abnormalities of spinal shape, the long axis of the spine moves out of the median sagittal plane, producing both an axial torsion and a lateral deviation out of the usual front-back plane. Clinicians need to be able to assess rapidly and accurately whether or not an individual has such an abnormality. In this paper, we examine several case studies. These are analyzed using some simple summary statistics, and the use of these methods to infer abnormality is demonstrated. Using a simple fitted model for the data, an angular estimate of abnormality is obtained. Empirical measures of abnormality based on the eigenvalues of the covariance matrix are also determined. These methods are applied to a number of individuals for whom the surface spinal profiles have been recorded and who have been assessed as normal or abnormal by clinicians.

Familial spinal shape

Journal of Applied Statistics, 1994

It has been proposed that there is a familial relationship in the shape of the spine. This paper ... more It has been proposed that there is a familial relationship in the shape of the spine. This paper describes a pilot study investigating familial shape in the sagittal plane (side view), using three data sets of normal Leeds schoolchildren. The study is exploratory in nature, because only small samples were available. Data acquisition was by means of the Quantec system,

A Survey of Current Controversies in Scoliosis Surgery in the United Kingdom

Spine, Aug 1, 2012

Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on ... more Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery, such as choice of implant, bone graft, autologous blood transfusion, cord monitoring, and computer-assisted surgery. Comparisons were then made with recommendations published in the spinal literature. Objective. To determine certain aspects of the current practice of scoliosis surgery in the United Kingdom. Summary of Background Data. Guidelines for good clinical practice in spinal deformity surgery are available in the United Kingdom but do not cover a number of controversial issues. Methods. Consultants and fellows attended the 2009 British Scoliosis Society meeting. Fifty questionnaires were completed by 45 consultants and 5 fellows. Results. All pedicle screw constructs favored by 25 of 50, hybrid 24 of 50 (1 undecided). Posterior construct of fewer than 10 levels, 20 of 50 would not cross-link, 11 of 50 used 1, and 19 of 20 used 2 or more. More than 10 levels 17 of 50 considered cross-links unnecessary, 4 of 50 used 1 and 29 of 50 used 2 or more. Eightyeight percent preferred titanium alloy implants, whereas others used a mixture of stainless steel and cobalt chrome. When using bone graft, respondents used bone substitutes (24), iliac crest graft (14), allograft (12) and demineralized bone matrix (9) in addition to local bone. Ten of 50 would use recombinant bone morphogenetic protein (3 for revision cases only). Thirty-nine of 50 routinely used intraoperative cell salvage and 4 of 50 never used autologous blood. All used cord monitoring: sensory (19 of 50), motor (2 of 50), and combined (29 of 50). None used computer-aided surgery. Twentysix operated alone, 12 operated in pairs, and 12 varied depending on type of case.

Current Practice in Scoliosis Surgery: A Survey of British Scoliosis Society Members

Orthopaedic Proceedings, Apr 1, 2012

To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was co... more To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence. Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows. All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case. This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature.

A Biomechanical Comparison of Bipedicular Versus Unipedicular Vertebroplasty in Cadaveric Osteoporotic Vertebra

Orthopaedic Proceedings, Apr 1, 2012

To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular V... more To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular Vertebroplasty in cadaveric vertebra Cadaveric single level vertebra were used to evaluate Bipedicular versus Unipedicular Vertebroplasty as an intervention for vertebral compression fractures Cadaveric vertebra were assigned to two arms: Arm A simulated a wedge fracture followed by bipedicular cement augmentation; Arm B simulated a wedge fracture followed by unipedicular cement augmentation. Micro-CT imaging was performed to assess vertebral dimension, cement fill volumes and bone mineral density. All augmented specimens were then compressed under a static eccentric flexion load to failure. Pre and post augmentation failure load and stiffness were used to compare the two groups. Results suggest, when compared with actual failure strength, that the product of bone mineral density and endplate surface area gave a good prediction of failure strength for specimens in both arms. The mean cement volume fill of augmented vertebral bodies was 22.8% ± 7.21%. The bipedicular group showed a reduction in stiffness but an increase in post augmentation failure load of 1.09. The unipedicular group also showed a reduction in stiffness but showed a much greater increase in post augmentation failure load of 1.68. Preliminary data from this study suggests there is a significant reduction in stiffness following both bipedicular and unipedicular vertebroplasty. There is a significant increase in failure load post augmentation in the unipedicular group.

Personalised image-based templates for intra-operative guidance

Proceedings Of The Institution Of Mechanical Engineers, Part H: Journal Of Engineering In Medicine, Feb 1, 2005

The high rate of unplanned perforation, poor fixation, and nerve injury with freehand pedicle scr... more The high rate of unplanned perforation, poor fixation, and nerve injury with freehand pedicle screw insertion has led to the use of image-guided navigation systems. Although these improve accuracy, they have several drawbacks that could be overcome by using image-based drilling guide templates. The accuracy of such templates was tested in a cadaveric study of screw placement in the lumbar, thoracic, and cervical regions of the spine. The dimensional stability with autoclaving of duraform polyamide, to be used for manufacturing the guides, was first determined using test specimens. Computed tomography (CT) images were acquired of 4 cadaveric spines, and placement of 4 cervical, 32 thoracic, and 14 lumbar screws was planned. Eighteen personalized drilling guide templates, in four different designs, were built. Orthopaedic surgeons experienced in the freehand techniques used the templates. CT images were acquired to assess placement position with respect to the pedicle. Duraform polyamide was found to be unaffected by sterilization. Two of the template designs facilitated the placement of 20/20 screws without error. Templates can lead to successful screw placement, even in small pedicles, providing their design is optimized for the application area, e.g. with enhanced rotational stabilization.

THU0028 an Explantion for How Viral Infection May Trigger Spondyloarthropathy Based on TLR9 Driven TNF Responses from Entheseal Derived Plasmacytoid Dendritic Cells

Annals of the Rheumatic Diseases, Jun 1, 2020

It is well known that viral infections may trigger psoriatic arthritis (PsA), a disease that typi... more It is well known that viral infections may trigger psoriatic arthritis (PsA), a disease that typically has extensive pre-clinical entheseal abnormalites. Skin resident plasmacytoid dendritic cells (pDCs) produce IFNα that contribute to T cell expansion and the development of experimental psoriasis [1, 2]. IFN pathway SNPs have been reported in both PsA and psoriasis and we previously reported the presence of pDCs at the human enthesis [3].To investigate whether the TLR9 agonist ODN that replicates viral infection activate a wide array of of entheseal derived pDCs molecular cascades including the TNF pathway that might provide a link between viral infection and PsA.pDCs were sorted from enthesis and blood and stimulated with ODN as previously described (n=16) [3, 4]. IFNα protein pre and post stimulation were detected by ELISA. Intracellular flow cytometry (IFC) of entheseal pDCs was used to detect TNF protein. RNA was extracted post-stimulation. The mRNA were hybridised and tagged by probes then measured on the nCounter platform. Data was analysed using nSolver 4.0. Log2 |fold change| >1 and P-value <0.05 were considered statistically significant. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) of differentially expressed genes (DEGs) were analyzed using DAVID. Protein-protein interaction (PPI) network was drawn by STRING.Stimulated entheseal pDCs showed a strong DEGs pattern pointing towards increased TNF expression. There were 11 genes significantly upregulated including TNF. RIPK3 is involved in TNF signalling pathway. TNF, RIPK3 and ZBP1 are involved in necroptosis. TNF and ITGB2 are involved in IL-4 and IL-13 signaling pathway. TNF, HLA-DOA, ITGB2/TLR7 are involved in virus infection. Together it highlights extremely activated TNF pathway genes.IFN protein was induced in sorted entheseal pDCs following stimulation (n=8). TNF protein was detected by IFC on stimulated entheseal pDCs (CD45+HLA-DR+CD123+CD303+ CD11c-) (n=3). We also compared entheseal and matched peripheral blood pDCs (n=8) following stimulation where no major differences in the TNF pathway were present between groups.The KEGG analysis was mapped in Figure 1. GO analysis showed the most significant change in biological processes was enriched in the positive regulation of DNA binding transcription factor activity. The change in molecular function was mainly enriched in p53 binding.Entheseal pDCs, upon viral molecule stimulation, show several markers of activation. However, TNF pathway genes were highly activiated which provides a novel mechanistic link between viral infection and PsA as reported in epidemiological studies.[1]Nestle, F.O., et al.,Plasmacytoid predendritic cells initiate psoriasis through interferon-alpha production.J Exp Med, 2005.202(1): p. 135-43.[2]Christophers, E., et al.,The risk of psoriatic arthritis remains constant following initial diagnosis of psoriasis among patients seen in European dermatology clinics.J Eur Acad Dermatol Venereol, 2010.24(5): p. 548-54.[3]Zhou, Q.,PLASMACYTOID DENDRITIC CELLS IN THE ENTHESIS: PHENOTYPING AND FUNCTION INVESTIGATION.Annals of the Rheumatic Diseases, 2019.78.[4]Bridgewood, C., et al.,Identification of myeloid cells in the human enthesis as the main source of local IL-23 production.Ann Rheum Dis, 2019.78(7): p. 929-933.Qiao Zhou: None declared, Jayakumar Vadakekolathu: None declared, Kassem Sharif: None declared, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Peter Millner: None declared, Peter Loughenbury: None declared, Abhay S Rao: None declared, Robert Dunsmuir: None declared, Charlie Bridgewood: None declared, Yasser El-Sherbiny: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

Complications in spinal deformity surgery in the United Kingdom: 5-year results of the annual British Scoliosis Society National Audit of Morbidity and Mortality

European Spine Journal, Jan 24, 2014

Purpose To provide a 5-year national overview of corrective spinal deformity surgery in the Unite... more 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 predefined 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 deficit (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, 9,295 corrective spinal deformity procedures were performed. 4,445 (48 %) were recorded as idiopathic and 2,917 (31 %) as non-idiopathic. There were a total of 339 complications (3.6 %). Deep infections occurred in 222 (2.82 %), incomplete neurological deficit with resolution in 59 (0.65 %), incomplete neurological deficit without resolution in 29 (0.32 %), complete neurological deficit in 12 (0.13 %) and mortality in 17 (0.19 %). Conclusion 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 figures 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.

A1.26 Innate lymphoid cells are present at normal human enthesis providing a potential mechanism for spondyloarthropathy pathogenesis

Annals of the Rheumatic Diseases, Feb 1, 2016

Scoliosis Secondary to Subphrenic Abscess

Spine, 1992

The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis, treatment and therapeutic outcomes

European Spine Journal, Apr 1, 2013

Purpose The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) ... more Purpose The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) is increasing. We performed a retrospective cohort study of patients with this type of infection in an effort to gain an improved understanding of the current clinical presentation, management and outcome. Methods Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from GNB HVO were identified and their microbiological diagnoses were evaluated. Results This study identified seventy-nine patients with haematogenous vertebral osteomyelitis (HVO). Of these seventy-nine patients, 10 patients (12.66 %) had Gramnegative organisms isolated. These organisms included Escherichia coli (4), Pseudomonas aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Eight patients were successfully treated with antibiotics and/or surgery. Of the eight patients whose HVO was cured, five had Ciprofloxacin as part of their definitive antibiotic regime. Conclusion The treatment of GNB HVO is often challenging because of unpredictable resistance patterns and limited published data on effective treatment regimens. Our study has highlighted the need for prompt microbiological sampling and initiation of early appropriate antibiotic regime. The most effective treatment for GNB HVO was with oral Ciprofloxacin over a period of 6-8 weeks.

$Research paper thumbnail of Spine fractures$

Spine fractures

The Incidence of Gram-Negative Haematogenous Vertebral Osteomyelitis in a Tertiary Referral Spinal Unit

Orthopaedic Proceedings, Jun 1, 2012

Purpose of study The aim of this study was to identify the incidence of Gram negative bacterial v... more Purpose of study The aim of this study was to identify the incidence of Gram negative bacterial vertebral osteomyelitis (VO) within our unit during a 3-year study period and evaluate if this corresponds to published evidence that the occurrence is increasing. Methods Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from Gram-negative VO were identified and their microbiological diagnoses were evaluated. All patients were treated within a large tertiary spinal surgery unit in Leeds. Results This study identified 79 patients with haematogenous VO. Of these 79 patients, 10 patients (12.66%) had Gram-negative organisms isolated. These organisms included E. Coli (4), Pseudomonal aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Four patients had the causative organism isolated on =2 positive blood cultures, three from biopsy and =2 positive blood culture, one from biopsy alone and two were diagnosed from 1 positive blood culture. Conclusion VO is a common manifestation of osteomyelitis in adults, representing 2-7% of all cases of osteomyelitis. Staphylococcus aureus is the most common causative aetiological agent in haematogenous spinal infections, accounting for between 40 - 60% of cases. Despite the fact that Gram negative bacteria infections represent a minor proportion of all cases of VO, around 15 - 23%, recent evidence suggests that the microbiology of this disease may be changing and the incidence of Gram-negative bacterial infections are increasing. This has been attributed a variety of factors including, an increasing proportion of individuals with predisposing risk factors such as advanced age, diabetes mellitus, malignancy and better diagnostic techniques. Results from our study show an incidence of Gram-negative VO of 12%, which is less than results quoted in the literature and does not confirm recent evidence that these types of spinal infections are increasing in incidence.

Peter Alexander Templeton

BMJ, May 2, 2012

Peter Alexander Templeton was born and grew up in Canada, where his father, also an orthopaedic s... more

Translaminar screw fixation of a kyphosis of the cervical and thoracic spine in neurofibromatosis

The journal of bone and joint surgery, Sep 1, 2009

Case report 745

Skeletal Radiology, Aug 1, 1992

Examination of the spine in childhood

Cambridge University Press eBooks, Jun 9, 2014

Late-Onset Idiopathic Scoliosis in Children Six to Fourteen Years Old. A Cross-Sectional Prevalence Study

Journal of Pediatric Orthopaedics, Mar 1, 1997

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed ... more We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Spinal injuries affecting the lumbosacral spine and pelvis

Orthopaedics and Trauma, Oct 1, 2016

Lumbo-sacral fractures are complex injuries that often occur alongside pelvic ring trauma. They a... more Lumbo-sacral fractures are complex injuries that often occur alongside pelvic ring trauma. They are often missed on initial assessment and plain radiography, and delayed treatment can lead to pain, reduced mobility and neurological compromise. Careful clinical examination is essential and identification of the fracture pattern often requires CT imaging. A large number of classification systems are available to help guide decision-making and these have recently been summarised in the comprehensive AO Spine sacral fracture classification system. Surgical intervention includes both neurological decompression and stabilisation and is indicated for patients with neurological compromise, lumbo-sacral instability and significant soft tissue injuries.

Estimated cumulative X-ray exposure and additional cancer risk during the evaluation and treatment of scoliosis in children and young people requiring surgery

Spine deformity, Mar 3, 2021

Introduction Clinicians and patients must weigh the benefits of radiological imaging against the ... more Introduction Clinicians and patients must weigh the benefits of radiological imaging against the risks of radiation exposure in the diagnosis and treatment of scoliosis. This report aims to estimate the cumulative absorbed and equivalent dose of radiation in patients undergoing surgical treatment for scoliosis, and to present this as an estimated risk of cancer compared to background radiation levels. Methods Retrospective review of estimated absorbed dose on the Computerised Radiology Information System (CRIS ®). Patients undergoing surgical correction of scoliosis (age ≤ 25) from August 2010 to August 2015 investigated. Estimated absorbed dose [milligrays (mGy)] recorded. Pedicle screws inserted using image intensification. Equivalent dose [millisieverts (mSv)] and additional cancer risk calculated from the National Research Council document 'Health risks from exposure to low levels of ionising radiation' (2006). Results 271 patients identified. Mean age 15 (range 2-25). Mean total absorbed dose 2136 mGy [standard deviation (SD) 1700 mGy]. Mean number of plain spine radiographs was 8 (SD 3) with total 1884 mGy exposure (SD 1609 mGy). Additional dose provided by CT (mean 0.17 episodes), plain chest and abdominal radiographs and image intensification. Mean number of image intensification episodes was 1.1 with mean estimated exposure 180 mGy (SD 238 mGy). Image intensification accounted for 8% of the estimated absorbed dose during treatment. Estimated mean effective dose delivered was 20.952 mSv equating to an additional cancer risk of 0.27-0.45%. Conclusion Additional cancer risk from cumulative imaging is small and equivalent to approximately 8 years of natural background radiation. Use of image intensification for pedicle screw insertion is a minor contribution (8%) to the total patient dose.

A study of three-dimensional curves

Journal of Applied Statistics, Feb 1, 1996

In certain abnormalities of spinal shape, the long axis of the spine moves out of the median sagi... more In certain abnormalities of spinal shape, the long axis of the spine moves out of the median sagittal plane, producing both an axial torsion and a lateral deviation out of the usual front-back plane. Clinicians need to be able to assess rapidly and accurately whether or not an individual has such an abnormality. In this paper, we examine several case studies. These are analyzed using some simple summary statistics, and the use of these methods to infer abnormality is demonstrated. Using a simple fitted model for the data, an angular estimate of abnormality is obtained. Empirical measures of abnormality based on the eigenvalues of the covariance matrix are also determined. These methods are applied to a number of individuals for whom the surface spinal profiles have been recorded and who have been assessed as normal or abnormal by clinicians.

Familial spinal shape

Journal of Applied Statistics, 1994

It has been proposed that there is a familial relationship in the shape of the spine. This paper ... more It has been proposed that there is a familial relationship in the shape of the spine. This paper describes a pilot study investigating familial shape in the sagittal plane (side view), using three data sets of normal Leeds schoolchildren. The study is exploratory in nature, because only small samples were available. Data acquisition was by means of the Quantec system,

A Survey of Current Controversies in Scoliosis Surgery in the United Kingdom

Spine, Aug 1, 2012

Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on ... more Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery, such as choice of implant, bone graft, autologous blood transfusion, cord monitoring, and computer-assisted surgery. Comparisons were then made with recommendations published in the spinal literature. Objective. To determine certain aspects of the current practice of scoliosis surgery in the United Kingdom. Summary of Background Data. Guidelines for good clinical practice in spinal deformity surgery are available in the United Kingdom but do not cover a number of controversial issues. Methods. Consultants and fellows attended the 2009 British Scoliosis Society meeting. Fifty questionnaires were completed by 45 consultants and 5 fellows. Results. All pedicle screw constructs favored by 25 of 50, hybrid 24 of 50 (1 undecided). Posterior construct of fewer than 10 levels, 20 of 50 would not cross-link, 11 of 50 used 1, and 19 of 20 used 2 or more. More than 10 levels 17 of 50 considered cross-links unnecessary, 4 of 50 used 1 and 29 of 50 used 2 or more. Eightyeight percent preferred titanium alloy implants, whereas others used a mixture of stainless steel and cobalt chrome. When using bone graft, respondents used bone substitutes (24), iliac crest graft (14), allograft (12) and demineralized bone matrix (9) in addition to local bone. Ten of 50 would use recombinant bone morphogenetic protein (3 for revision cases only). Thirty-nine of 50 routinely used intraoperative cell salvage and 4 of 50 never used autologous blood. All used cord monitoring: sensory (19 of 50), motor (2 of 50), and combined (29 of 50). None used computer-aided surgery. Twentysix operated alone, 12 operated in pairs, and 12 varied depending on type of case.

Current Practice in Scoliosis Surgery: A Survey of British Scoliosis Society Members

Orthopaedic Proceedings, Apr 1, 2012

To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was co... more To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence. Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows. All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case. This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature.

A Biomechanical Comparison of Bipedicular Versus Unipedicular Vertebroplasty in Cadaveric Osteoporotic Vertebra

Orthopaedic Proceedings, Apr 1, 2012

To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular V... more To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular Vertebroplasty in cadaveric vertebra Cadaveric single level vertebra were used to evaluate Bipedicular versus Unipedicular Vertebroplasty as an intervention for vertebral compression fractures Cadaveric vertebra were assigned to two arms: Arm A simulated a wedge fracture followed by bipedicular cement augmentation; Arm B simulated a wedge fracture followed by unipedicular cement augmentation. Micro-CT imaging was performed to assess vertebral dimension, cement fill volumes and bone mineral density. All augmented specimens were then compressed under a static eccentric flexion load to failure. Pre and post augmentation failure load and stiffness were used to compare the two groups. Results suggest, when compared with actual failure strength, that the product of bone mineral density and endplate surface area gave a good prediction of failure strength for specimens in both arms. The mean cement volume fill of augmented vertebral bodies was 22.8% ± 7.21%. The bipedicular group showed a reduction in stiffness but an increase in post augmentation failure load of 1.09. The unipedicular group also showed a reduction in stiffness but showed a much greater increase in post augmentation failure load of 1.68. Preliminary data from this study suggests there is a significant reduction in stiffness following both bipedicular and unipedicular vertebroplasty. There is a significant increase in failure load post augmentation in the unipedicular group.

Personalised image-based templates for intra-operative guidance

Proceedings Of The Institution Of Mechanical Engineers, Part H: Journal Of Engineering In Medicine, Feb 1, 2005

The high rate of unplanned perforation, poor fixation, and nerve injury with freehand pedicle scr... more The high rate of unplanned perforation, poor fixation, and nerve injury with freehand pedicle screw insertion has led to the use of image-guided navigation systems. Although these improve accuracy, they have several drawbacks that could be overcome by using image-based drilling guide templates. The accuracy of such templates was tested in a cadaveric study of screw placement in the lumbar, thoracic, and cervical regions of the spine. The dimensional stability with autoclaving of duraform polyamide, to be used for manufacturing the guides, was first determined using test specimens. Computed tomography (CT) images were acquired of 4 cadaveric spines, and placement of 4 cervical, 32 thoracic, and 14 lumbar screws was planned. Eighteen personalized drilling guide templates, in four different designs, were built. Orthopaedic surgeons experienced in the freehand techniques used the templates. CT images were acquired to assess placement position with respect to the pedicle. Duraform polyamide was found to be unaffected by sterilization. Two of the template designs facilitated the placement of 20/20 screws without error. Templates can lead to successful screw placement, even in small pedicles, providing their design is optimized for the application area, e.g. with enhanced rotational stabilization.

THU0028 an Explantion for How Viral Infection May Trigger Spondyloarthropathy Based on TLR9 Driven TNF Responses from Entheseal Derived Plasmacytoid Dendritic Cells

Annals of the Rheumatic Diseases, Jun 1, 2020

It is well known that viral infections may trigger psoriatic arthritis (PsA), a disease that typi... more It is well known that viral infections may trigger psoriatic arthritis (PsA), a disease that typically has extensive pre-clinical entheseal abnormalites. Skin resident plasmacytoid dendritic cells (pDCs) produce IFNα that contribute to T cell expansion and the development of experimental psoriasis [1, 2]. IFN pathway SNPs have been reported in both PsA and psoriasis and we previously reported the presence of pDCs at the human enthesis [3].To investigate whether the TLR9 agonist ODN that replicates viral infection activate a wide array of of entheseal derived pDCs molecular cascades including the TNF pathway that might provide a link between viral infection and PsA.pDCs were sorted from enthesis and blood and stimulated with ODN as previously described (n=16) [3, 4]. IFNα protein pre and post stimulation were detected by ELISA. Intracellular flow cytometry (IFC) of entheseal pDCs was used to detect TNF protein. RNA was extracted post-stimulation. The mRNA were hybridised and tagged by probes then measured on the nCounter platform. Data was analysed using nSolver 4.0. Log2 |fold change| >1 and P-value <0.05 were considered statistically significant. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) of differentially expressed genes (DEGs) were analyzed using DAVID. Protein-protein interaction (PPI) network was drawn by STRING.Stimulated entheseal pDCs showed a strong DEGs pattern pointing towards increased TNF expression. There were 11 genes significantly upregulated including TNF. RIPK3 is involved in TNF signalling pathway. TNF, RIPK3 and ZBP1 are involved in necroptosis. TNF and ITGB2 are involved in IL-4 and IL-13 signaling pathway. TNF, HLA-DOA, ITGB2/TLR7 are involved in virus infection. Together it highlights extremely activated TNF pathway genes.IFN protein was induced in sorted entheseal pDCs following stimulation (n=8). TNF protein was detected by IFC on stimulated entheseal pDCs (CD45+HLA-DR+CD123+CD303+ CD11c-) (n=3). We also compared entheseal and matched peripheral blood pDCs (n=8) following stimulation where no major differences in the TNF pathway were present between groups.The KEGG analysis was mapped in Figure 1. GO analysis showed the most significant change in biological processes was enriched in the positive regulation of DNA binding transcription factor activity. The change in molecular function was mainly enriched in p53 binding.Entheseal pDCs, upon viral molecule stimulation, show several markers of activation. However, TNF pathway genes were highly activiated which provides a novel mechanistic link between viral infection and PsA as reported in epidemiological studies.[1]Nestle, F.O., et al.,Plasmacytoid predendritic cells initiate psoriasis through interferon-alpha production.J Exp Med, 2005.202(1): p. 135-43.[2]Christophers, E., et al.,The risk of psoriatic arthritis remains constant following initial diagnosis of psoriasis among patients seen in European dermatology clinics.J Eur Acad Dermatol Venereol, 2010.24(5): p. 548-54.[3]Zhou, Q.,PLASMACYTOID DENDRITIC CELLS IN THE ENTHESIS: PHENOTYPING AND FUNCTION INVESTIGATION.Annals of the Rheumatic Diseases, 2019.78.[4]Bridgewood, C., et al.,Identification of myeloid cells in the human enthesis as the main source of local IL-23 production.Ann Rheum Dis, 2019.78(7): p. 929-933.Qiao Zhou: None declared, Jayakumar Vadakekolathu: None declared, Kassem Sharif: None declared, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Peter Millner: None declared, Peter Loughenbury: None declared, Abhay S Rao: None declared, Robert Dunsmuir: None declared, Charlie Bridgewood: None declared, Yasser El-Sherbiny: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

Complications in spinal deformity surgery in the United Kingdom: 5-year results of the annual British Scoliosis Society National Audit of Morbidity and Mortality

European Spine Journal, Jan 24, 2014

Purpose To provide a 5-year national overview of corrective spinal deformity surgery in the Unite... more 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 predefined 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 deficit (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, 9,295 corrective spinal deformity procedures were performed. 4,445 (48 %) were recorded as idiopathic and 2,917 (31 %) as non-idiopathic. There were a total of 339 complications (3.6 %). Deep infections occurred in 222 (2.82 %), incomplete neurological deficit with resolution in 59 (0.65 %), incomplete neurological deficit without resolution in 29 (0.32 %), complete neurological deficit in 12 (0.13 %) and mortality in 17 (0.19 %). Conclusion 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 figures 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.

A1.26 Innate lymphoid cells are present at normal human enthesis providing a potential mechanism for spondyloarthropathy pathogenesis

Annals of the Rheumatic Diseases, Feb 1, 2016

Scoliosis Secondary to Subphrenic Abscess

Spine, 1992