Patients with mechanical back pain have been treated in a nurse-led spinal clinic. They attend two one-on-one sessions with a nurse, the second session usually between three and 12 months after the first. Between these visits, they also attended two sets of classes in the spinal assessment clinic to help them improve and manage their back pain. A questionnaire is completed at presentation and at review. The questionnaires include three scores: The low back outcome Score, MSPQ and the Zung Depression Scale. Since 1995, approximately 2250 patients have been treated. The influence of smoking, gender, age, occupation and marital status on recovery has been studied. Smoking: Patients who had given up smoking between the first and second questionnaires showed a significant improvement in their outcome score and MSPQ score. Out of 827 who said they smoked on presentation, 280 said they did not on review. From an average outcome score on presentation of 25, those who gave up improved more than those who did not (average score at review 37 vs. 31). A similar trend was seen in the MSPQ averages (from 9 to 7.4 vs. 9 to 8.7). Non-smokers had better results than smokers with an increased outcome score from 30 to 38, MSPQ from 8 to 7.1 and Zung from 20.6 to 19.6. Thus people who gave up smoking showed a larger improvement in their outcome and MSPQ scores than those who continued smoking and those who did not smoke at all. Gender: Women showed greater improvement in each of the areas than men – 14.5% greater in the outcome score, a 21.2% greater increase in the MSPQ score, and 3.7% in the Zung score. Age: Patients were divided into 10-year groups. The age group of 50–60 showed the lowest average response for each score, ( 28 to 34 on outcome (average difference = 8), 8.3 to 7.8 on MSPQ (average difference = −0.8), and 21.1 to 21 on Zung (average difference = −0.7). The 30–40 group showed the highest average change on each score (29 to 39 on outcome, 7.9 to 6.9 on MSPQ, 21.8 to 20.1 on Zung). The adjacent age groups showed similar trends but the numbers were not significant. Occupation: Occupation was divided into eight categories from high-grade professionals to the unemployed. The least improvement was shown by the low-grade occupations (semi-skilled manual workers and the unemployed). The greatest improvements were shown by the middle grade groups. The highest grade occupation showed poor improvement but this was not significant. Marital Status: For the outcome score, patients who were divorced/separated showed the least improvement, while the married group showed the greatest. On the MSPQ and Zung score, divorced/separated showed the greatest and second greatest improvement (61 % greater than the average on Zung score). The single group showed the worst overall response, scoring the second lowest improvement for the outcome score, the lowest on the MSPQ score (difference −0.47) and their average response actually worsened for the Zung score (from 21 to 21.6). Conclusion: This study demonstrates that demographic and socio-economic factors significantly influence the level of improvement which patients make in their recovery from mechanical back pain after a treatment program

Purposes of Study and Background: To survey beliefs and attitudes about the management of mechanical back pain in General Practitioners (GPs) in two cities in the East Midlands, and to compare the findings with a similar recent Australian study. We also conducted a ‘found experiment’ on the use of ‘The Back Book’ by the GPs in the two cities following the purchase and distribution of its copies to the GPs in Leicester by the local Primary Care Trusts. There has been a paradigm shift in the management of mechanical low back pain in the last ten years. Several different clinical guidelines are available based on current evidence in the literature. There is little to show how far these guidelines are being implemented. There are no studies of the barriers to implementation in the British population. Methods and Results: A postal questionnaire consisting of ten questions, eight of which were taken from a questionnaire used in a similar survey from Australia. Two additional questions relating to the ‘Back Book’ were included. 164 GPs in the city of Leicester and 353 in the city of Nottingham were surveyed in August – September 2001. The response rate was 70.1% (115) from Leicester and 65.7% (232) from Nottingham. The majority of GPs from both cities were aware of the current concepts about the management of mechanical back pain. The awareness and usage of “The Back Book” was significantly better amongst the GPs in Leicester (p < 0.001). Conclusion: General practitioners in two cities in Trent region are well aware of current best practice in the management of acute back pain. Their attitudes and beliefs towards back pain management compared well if not better in some aspects, with those of their Australian counterparts. If the resource of ‘The Back Book’ is made available then GPs will use it, in keeping with current best evidence

Purpose of the study and background. The preliminary study aimed to establish clinical and research expert opinion with regards to the key components of an assessment of a person with Mechanical Low Back Pain (MLBP). We aimed to identify the key subjective questions and objective tests which would be helpful for clinicians to develop the most appropriate self-management exercise programme. This is the first part of the study to develop the ‘Back-to-Fit’ digital tool offering personalised self-management exercise solutions for people with MLBP. Summary of the methods. A Bristol online survey which included a questionnaire with a series of open and closed questions was developed using the literature and was distributed among clinicians/researchers with a background in the clinical management of MLBP. The questionnaire included 6 demographic questions followed by sections related to subjective questions and objective tests of the MLBP assessment. 71 participants responded to the survey. Results. In the subjective assessment component, ≥80% level of agreement was obtained for 17 of 26 proposed subjective questions and 05 of the 21 suggested objective tests. Two more questions and two objective tests to be included in the assessment had been suggested by the partcipants. Conclusion. These expert agreements on questions and opinions provides an indication of the key subjective and objective components to be included in a self-assessment tool in a personalised self-management platform for MLBP. Further testing with a multiple round Delphi study in a large sample of experts is now required to obtain consensus for the above findings. Conflicts of interest: No conflicts of interest. Sources of funding: Biomechanics and Bioengineering Research Centre Versus Arthritis, Cardiff University, UK

Background

Low back pain (LBP) is widespread in all populations and is a worldwide health problem, which poses substantial challenges for clinical management. Individuals with LBP may reduce their symptoms by implementing self-managed at-home interventions. The theoretical design of the LumbaCurve™ promotes the principles of a passive gravity-assisted traction (PGAT) stretch of the lumbar and sacral region in order to reduce LBP. This study aimed to assess the clinical effectiveness of the LumbaCurve™ in the management of LBP when compared to a control group of standardised care.

Aims: The aim of the present study was to investigate the correlation between the topography of the reported symptoms of ‘mechanical’ lower back pain and the findings from the MRI of the lumbar spine.

Methods: Topography (‘pain charts’) of the lower back pain (upper, middle, lower lumbar and sacro-iliac areas) and the MRI findings (disc morphology, Modic-type end plate changes, presence and degree of spondylolisthesis) of 230 consecutive patients with ‘mechanical’ lower back pain without neurological symptoms were studied. Chi-square test was used for the statistical analysis.

Results: Analysis showed that the presence of L5/S1 level pathology is associated (p=0.018) with pain in the middle lumbar area. No other statistically significant association between pathology of another level and pain in other lumbar areas was observed.

Conclusions: Contrary to the general belief, pathology of the lowest lumbar spinal level as diagnosed from MRI may be associated with pain in the middle lumbar area while other pathological levels are not necessarily associated with specific areas of pain in the lower back.

Aim: Since 1994, we have used virtually identical criteria to the Swedish Lumbar Spine Study Group before accepting patients for instrumented posterolateral spinal fusion. We review these criteria and the surgical outcome and compare them with those of the SLSSG. Method: 26 patients underwent posterolateral lumbar spinal fusion with Moss-Miami instrumentation between 1994 and 2001 for intractable LBP. Patients selected for surgery had to meet strict inclusion criteria. These were: severe intractable LBP causing significant work or recreational disability which failed to respond to all reasonable non-operative measures; absence of leg pain; no spondylolisthesis or spondylolysis; no neurological signs; no claudication; no other pathology i.e. mechanical/discogenic LBP only; no disc protrusion on MRI; no clinical evidence of learnt illness behaviour; L5/S1 or L4/L5 black discs on MRI, and no black discs above these levels; no litigation or compensation claim in process. Patients were assessed at a minimum of 1 year (range 14–95 months) using the NASS lumbar spine follow-up form, and postoperative radiographs to assess the fusion mass. Results: There were no deaths or significant complications of surgery. 84% of patients showed substantial improvement, 16% were improved but with significant residual pain. None were unchanged or worse. Fusion rate was 92%. Only two patients would not have undergone the same procedure again. Conclusion: We believe that these criteria form a sound basis for selecting patients with severe intractable LBP who might benefit from a posterolateral fusion.

Background context: It is frequently stated that referred pain does not travel below the knee. However, for many years studies provoking referred pain have demonstrated pain radiating below the knee. Methods: Over a twelve month period, 643 patients with mechanical back pain and 185 patients with nerve root compressions were seen. For each patient two body map images (front and back) were obtained. Some patients attended for review, at a minimum of six weeks after their first visit. These images were also analysed. Composite images were created by combining all images from patients in one diagnosis group. Colour based overlays were used to analyse the body map images, to locate the locations of pain. Colour density was scaled so that the site with the most hits had a pure colour, reducing down to zero colour for sites with no hits. Results: There were 720 nerve root compression images. 216 (30%) showed no leg pain, 91 (12.6%) showed upper leg pain, 134 (18.6%) showed lower leg pain and 279 (38.8%) showed upper and lower leg pain. There were 1964 mechanical back pain images. 674 (34.3%) showed no leg pain, 528 (26.9%) showed upper leg pain, 308 (15.7%) showed lower leg pain and 454 (23.1%) showed upper and lower leg pain. Conclusion: A large proportion (39%) of the mechanical back pain images indicated that the patient experienced referred pain below the knee. This has significant implications in the diagnosis of nerve root compressions, potentially leading to inappropriate surgery. Conflicts of Interest: None. Source of Funding: None

Aim: Examine how individuals on Teesside, diagnosed with mechanical back pain, socially construct the beliefs they hold about their back problem. The Spinal Assessment Clinic, at Middlesbrough General Hospital, uses a comprehensive and co-ordinated approach when assessing and treating individuals. More information demonstrating how people suffering with mechanical back pain are influenced by their psychosocial and cultural beliefs would enable the team to enhance the process. This research, is an anthropological examination of individual’s thoughts and beliefs as they absorb the information extended to them. This will be valuable in enhancing clinicians, sufferers and academics understanding of back pain. The research is still in the recruitment phase. Method: This is an ethnographic study using a phenomenological framework to interpret the narrative and pictorial accounts given by individuals suffering with mechanical back pain as they proceed through their treatment at Spinal Assessment Clinic. Interviews are informal, the intention being to listen to each individuals life story and explore the way in which the narratives evolve, as they explain the lived experience of their pain. Individuals are being recruited from the Spinal Assessment Clinic. One of the research methods utilised is that of pain imagery, with volunteers providing a drawing, representing their back pain. Results: The drawings demonstrate that physical pain is not always viewed by individuals as a biological problem, it may be externalised or expressed as an emotion. The images are filled with vivid metaphors symbolising each individuals unique interpretation of their pain. Conclusion: Initial results demonstrate there is a gap between the patients’ visualisation in their drawing and the narrative accounts provided

Background and purpose of the study. Axial Spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5- 8 years with impacts on effective and timely management, outcomes and quality of life. NICE Guidance (2017) highlights the importance of the recognition and referral of suspected axial spondyloarthritis. This study investigated the occurrence of physiotherapy care prior to diagnosis of axSpA within physiotherapy outpatient settings. Methods and results. A retrospective review was performed of all patients diagnosed with axSpA who had received physiotherapy care prior to their diagnosis from 1990–2016. Three or more episodes of care prior to diagnosis was taken as unrecognised axSpA. Information was obtained on diagnostic codes, number of episodes of care and contacts per episode from nine outpatient physiotherapy services. Analysis showed that 263 people (17–69 years) diagnosed with axSpAs had received physiotherapy care prior to diagnosis. Within this population, 103 (44%) had received ≥3 episodes of care. Number of contacts within each episode ranged from 3 (47 people) to 58 (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy episode to date of diagnosis was 6.4 years (range=0.3–12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Conclusion. Findings illustrate the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal physiotherapy practice. It is essential to improve screening and recognition of inflammatory back pain and possible axSpA in musculoskeletal assessments, supported by rheumatology referral guidance. No conflicts of interest. No funding obtained

Introduction: The purpose of this research is to use an anthropological approach to examine the narratives of individuals living in Teesside, who have been diagnosed with mechanical back pain at a nurse led Spinal Assessment Clinic. The narratives that people use to construct their back pain must be taken into account if they are to be helped, as their beliefs about their problem will impact upon their expectations and compliance. Method: After their first appointment in the Spinal Assessment Clinic, individuals who were diagnosed with mechanical back pain were invited to join the research. Each individual was interviewed three times as they progressed through the clinic system. The second time was after they had or had not attended the back pain management classes. The last interview was after their final review and they were discharged from the clinic. The interviews were casual with very little input from the researcher. Conclusion: Individuals appear to have a hidden agenda when they attend the clinic and this helps them to decide whether to accept or dismiss their diagnosis. The narrative used by the multidisciplinary team is interpreted according to each persons agenda often leaving individuals with a totally different interpretation to that intended by the multi disciplinary team. People appear to tell clinicians what they think they want to hear, but during their interviews for this research different narratives often emerged. Listening to people’s life stories and examining the narrative they use to explain their back problems can enable the multi disciplinary team to better understand individuals and their problems and assist in their own professional development as well as improving services for patients

Introduction: After a year in post, the waiting time to see the spinal surgeon in a large hospital had risen from 0–62 weeks. A nurse-led assessment clinic was inaugurated to triage patients, cut waiting times and accelerate treatment. Methods: Referrals were taken directly from general practitioners, and patients triaged using proforma history and examination systems into five categories: mechanical back pain, nerve root entrapment, potentially serious pathology, unknown diagnosis and suitable manipulative therapy. Audit based on direct patient entry with a light pen interface was integrated into the process. Seventy percent of patients were referred complaining of mechanical back pain, and an Educational Rehabilitation Programme was provided within the clinic. Results: Following the inauguration of the spinal assessment clinic, waiting times in the consultant clinic fell from 62 weeks to 26 weeks; waiting times in the assessment clinic were between four and six weeks. Emergencies may be seen the same week. The time from GP referral to surgery for routine nerve root compression fell from 92 weeks to 24 weeks (of which 12 weeks was waiting time for scanning). Detailed audit of scanning requests in 127 patients demonstrated confirmation of clinical diagnosis in 80 percent of whom half went on to surgery. Of the 20 percent with negative scans, a fifth were subsequently found to have trochanteric bursitis. An audit of 94 patients revealed reduced analgesic consumption, increased return to work and reduced consultation rates at one year. Five patients were referred to other clinics for further consultation. The satisfaction of the clinic amongst general practitioners was 94 percent. Referrals to the clinic have risen from 403 in 1993 to 1511 in 1999, necessitating the appointment of three further nurse practitioners. Prospective review of 104 patients revealed 95 percent satisfaction rate of the clinic and 67 percent satisfaction rate with rehabilitation. Average low back outcome score increased from 29 to 35 (p< 0.001). A training programme for nurse practitioners has been established and, to date, ten of the clinics have been inaugurated nation-wide using this model. Conclusions: A nurse-led clinic for triage of back pain patients has had major impact on waiting times, has produced measurable improvements in patients’ outcome and is associated with high satisfaction ratings in both patients and general practitioners

Study Design: We describe innovative minimally invasive Israeli made Expandable Spinal Fusion System for lumbar spinal fusion, in patients with all caused of mechanical back pain: Degenerative Disc Disease (DDD) at one or two levels from L2–S1, up to Grade l spondylolysthesis. The purpose of the study was to provide a preliminary evaluation of the safety and efficacy of the Expandable Spinal Fusion System in establishing vertebral stability and fusion, and in improving the quality of life of the patients. The relatively large diameter of currently used cages dictates extensive manipulations, damaging structures that are crucial for spinal stability. The Expandable Spinal Fusion System, is 5 mm in diameter in closed configuration, applied in a minimally invasive technique, through a 6mm entering opening by an open or percutaneous posterior procedures. Once in position, its dimensions are increased to a precut size in a controlled procedure. Thus, this system maintains the integrity of facet joints, with no or minimal laminectomy, and minimal damage to the surrounding tissues. Methods: Data were collected in a series of 60 patients with DDD in levels L3–S1. The patients wee operated in the open posterior approach with or without Pedicle Screws and percutaneous posterolateral. Both end-plates faces were treated by special curettes and partially removed. Posterior iliac bone graft was used and 2 tubes device were introduced to the inter-somatic space under direct vision controlled by X-rays C-Arm intensifying magnification. Data: The implantation approach was posterior in 52 patients, anterior in 2 and percutaneous in 6 patients. Maximal follow up period is 12 months. Patients follow up was completed according to investigational protocol mandate follow up visit at 1.5, 3, 6, 12 months postoperatively. The main at the time of the surgery was 52 years old. 57 underwent surgery at one level as follows: 3 at L3-L4, 32 at L4-L5, and 21 at L5-S1, and 3 underwent surgery at two levels. Patient questionnaire pain and quality of life was evaluated using the Oswestry questionnaire and VAS measurement. The patient fill those pre-operatively and at each follow up visit. Results: Although follow up period is short according to preliminary data, the Expandable Spinal Fusion System has proved to be safe, effective, as well as easy to handle for treating all cases of mechanical back pain: DDD. There was no neurological injury, no infection, no death and no worsening of clinical symptoms. There was no breakage or migration of the implant at the last follow-up. Flexion-Extension X-ray show good stability. VAS score for pain dropped from 8 pre op to 2.6 in average 3 months post-op

During the last 2 decades it has been recognized that scoliosis may start de novo during adult life as a result of advanced degenerative disc disease, osteoporosis or both. In some the degenerative process is superimposed on a previous adolescent curve. Aside from the disfigurement caused by the spinal deformity, pain and disability are usually the major clinical problem. The prevalence of adult scoliosis rises with age: from 4% before age 45, 6% at age 59 to 15% in-patients older than 60 years. More than two thirds of the patients are females and the prevalence of right lumber curves is higher than in comparable series of patients with adolescent scoliosis. Adult scoliosis is characterized by vertebral structural changes with translatory shifts i.e. lateral olisthesis accompanied by degenerative disc and facet joint arthrosis. Although the magnitude of these curves is usually mild (20–30 degrees) lateral spondylolisthesis is observed frequently. It is also common to observe degenerative spondylolisthesis in patients with degenerative lumbar scoliosis. The annual rate of curve progression ranges from 0.3 to 3%. Patients present with a history of a spinal deformity accompanied by loss of lumbar lordosis, trunk imbalance and significant mechanical back pain. Pain may arise not only from degenerative disc disease and facet arthritis leading to symptoms of spinal stenosis, but also from muscle fatigue due to the altered biomechanics secondary to a deformity in the coronal and sagittal planes. Root entrapment is common and occurs more often on the concavity of the curve. Symptoms of neurogenic claudication are also common in adults with lumbar scoliosis. Non-operative care includes exercises, swimming, NSAIDs, and occasional epidural injections. Brace treatment can be tried as well. Curve progression as well as axial or radicular pain not responding to non-operative care are indications for surgical intervention. Surgery may include decompression alone or in conjunction with curve correction and stabilization. Posterior instrumentation may be supplemented with interbody cages. Fusion is usually carried down to L5 but occasional instrumentation to the sacropelvis is mandatory. Problems with a high pseudoarthrosis rate are common with sacral fixation. Even in the best of hands a long recovery period (6–12 month) and moderate pain relief should be expected. As summarized by Dr. Bradford “despite recent advancements evaluation and successful management of patients with adult spinal deformity remains a significant challenge”

Purpose of study: Non-fusion stabilisation of degenerative lumbar spine with hinged pedicle screws provides an alternative to spinal fusion in preventing junctional breakdown. Methods and Results: In this prospective cohort study, clinical, functional (Roland-Morris Disability Scale 18 question version) and radiological assessment of patients was performed pre-operatively and postoperatively at predetermined intervals. 36 patients were reviewed with a mean follow-up of 18 months (12 – 28 months). The indications of operation were symptomatic spinal stenosis, discogenic mechanical back pain, post discectomy syndrome and revision spinal surgery. Average age was 57 years (35 – 78 years). Average pre-operative duration of back pain was 6 years (2 – 25 years). 18 patients had stabilisation of single motion segment, 12 had two adjacent motion segments stabilised and six had three segments stabilised. 28 patients had spinal decompression along with stabilisation. On excluding one patient with wound infection average hospital stay was 5 days. There were 78 rods and 192 pedicle screws used with in-situ breakage of two screws and loosening of one screw. Functional score (Roland-Morris Disability Scale 18 question version) improved from 11.33 to 4.44. Visual analogue score (VAS 0 – 100) improved from 79.29 to 13.29. Subjective outcome, measured with descriptive analogue scale, showed marked improvement in 76% of patients. Conclusion: The posterior dynamic stabilisation eliminates the risks and complications of fusion surgery. Although long term results are not available yet but considering early results, this technique can be used safely as a first line surgical treatment for degenerate lumbar spine

Introduction: Delay in active management reduces the prognosis for simple low back pain. The aim of this project was to develop a tool for use in GP surgeries to assist the doctor in his/her diagnosis of lower back pain and allow prompt management with confidence. Methods: Three different systems for the automated diagnosis of low back pain were developed. With each, the patient answered a series of questions presented by the system. Three different strategies were employed, one using variable weighting, one a logic tree and one an inference engine. For the purpose of testing the systems against each other, a database was constructed containing the answers to all possible questions from each system for one hundred patients attending a low back pain clinic. The “true” diagnosis was that made by the treating clinician who saw the patients. The original data contained a number of diagnoses:. Spinal Stenosis (central or lateral). Prolapsed Intervertebral Disc. Other Nerve Root Compression (NRC). Mechanical Back Pain (MBP) with NRC. Pure MBP. For the purpose of the comparison two groups were considered – patients with radicular symptoms (groups 1 to 4) and patients with pure MBP. Conclusions: The different approaches to development showed that a number of factors play a crucial role for the accuracy of the systems, including the number of rules used to try to cover every possibility, the interpretation of the questions by the patients and the weighting and approach taken for the different Certainty Factors. The use of any of these three approaches did not allow the development of a system accurate enough for clinical use and it seems that successful development of such a system might require a wholly different approach

Spondylolytic spondylolisthesis is one of the common causes of mechanical low back pain in adults. Conservative treatment of such cases, particularly for the low grade slips, remains the mainstay of management. When patients’ symptoms are marked and not responsive to conservative therapy, the surgical option can be considered. Up to the time of writing this abstract [January 2003], arthrodesis of the affected motion segment with or without instrumentation is the standard surgical option for treating mechanical low back pain. Results of different types of arthrodesis for treating such condition had been reported in literature, including posterior fusion, posterolateral fusion, and posterior and anterior interbody fusion. Between 1993 and 1998, seventy- five adult patients with grade I or II lytic spondylolisthesis were treated by in situ posterolateral fusion and segmental instrumentation using the Oswestry Pedicle Screw System, with or without extended Gill’s procedure. The indications for surgical intervention in these cases were significant reduction in the quality of life with persistent low back pain and/or leg pain after a minimum of six months conservative therapy. Confirmatory imaging studies consistent with the clinical data should also be obtained before deciding the surgical option. The average operative time was 2.5 hours [range 2–4 hours). The average blood loss was 850 mls (range 300–2300 mls). After an average follow-up of 60.7 months (range 24–95 months) clinical results were excellent and good in 92%, and radiological union was achieved in 94% of patients. Complications included 2 cases with superficial wound infection, one case with deep wound infection, and four of the patients went to non-union. In conclusion, with a careful patient selection, patients with instrumental insitu posterolateral fusion gained a satisfactory clinical and radiological outcome and the results were maintained for an adequate postoperative period

Purpose of the study: To study clinical, radiological and pathological features of this rare condition and to observe the effect of surgery on the relief of presenting symptoms. Materials, Methods and Results: between February 1989 to May 1999, more than 200 spinal operations were carried out at Oswestry, amongst which we found 11 patients with 13 symptomatic lumbar synovial cysts. Nine patients were female and 2 were male. Among the symptoms produced, sciatica was present in 10 out of 11 patients, neurologic claudication was present in 6 patients and only one patient had neurologic deficit. All the patients suffered with back pain, which was either of facetal origin or mechanical back pain. Radiological investigations revealed that all patients had evidence of facet arthrosis. Seven patients had degenerative spondylolisthesis. Degenerative disc disease was also seen in 7 patients. The contents of the cysts varied from serous fluid to chalky white material to gelatinous grey material. One cyst contained calcium pyrophosphate crystals. Another cyst contained hydroxyapatite crystals. Seven cysts which contained deposition of bone debris in the cyst wall also revealed an (giant cell and macrophage) inflammatory reaction to this bone debris. In all patients complete resolution of sciatica, neurologic claudication and neurologic deficit was observed after surgery. However, after a minimum follow up of two years the back pain persisted in all but one patient. Conclusion: Lumbar synovial cyst is a rare condition, more common in females, elderly, and occurs most commonly in association with degenerative disease of the spine, although it can also be caused by other conditions like trauma, or rheumatoid arthritis. When they cause compression of the dura or nerve roots, they present with symptoms like sciatica and neurologic claudication, which resolve promptly after surgery. However, patients also have a long history of back pain from the associated degenerative spinal disease which usually does not resolve unless it is addressed separately and patients need to be warned regarding this

Objective: Assess outcomes following a three-month multi-disciplinary spinal rehabilitation program for chronic low back pain, based in the community in a £10 million sports centre. Design: This was a prospective study with data being collected before and at the completion of the programme. The programme team consists of an orthopaedic surgeon, physiotherapists, fitness instructor, nurse counsellor and a secretary. The programme included a graded aerobic fitness programme, spinal stabilisation programme, cognitive behavioural therapy, hydrotherapy and occupational therapy. Subjects: 112 patients with chronic mechanical back pain. Mean duration of symptoms 9.1 years. Mean age was 46 years: 52 women and 60 men. Outcome Measures: Included visual analogue score, Oswestry Disability Score (OSW), lumbar motion velocity, shuttle walking test, lifting endurance, isometric strength of spinal extension and flexion and the return to work rate. Results: Mean VAS back pain and leg pain scores reduced from 6.6 to 4.1 and 3.7 to 2.2 respectively (p< 0.001). Mean OSW decreased from 34.6% to 21.7% (p< 0.001). Back pain improved by 37% and the Oswestry score by 42%. Only three of the 112 patients went on to have surgery. Mean lumbar motion velocity improved from 114 to 161 degrees/second (P< 0.001). Shuttle walking test improved from 458 to 644 metres (p< 0.001). Mean lifting maximum improved from 16.1 to 19.3Kg (p=0.005). Lifting endurance improved from 51 to 38 seconds. Mean Isometric spinal extensor strength improved from 24.2Kg to 48.6Kg and flexion from 25.7 to 49.4Kg (p< 0.001 in all cases). Thirty-eight percent of patients were unemployed before the program and 10% after the program. Patients also reported needing less analgesia, having more confidence, feeling happier and their flare-ups settling more quickly. Conclusions: This three-month programme delivered significant improvements in back pain, disability, strength and endurance capacity and a return to work rate, in this cohort of chronic back pain patients

Purpose and Background: There is increasing evidence that events within the diseased intervertebral disc (IVD) are mediated by locally synthesised cytokines. A prominent histological, imaging and surgical feature of IVD disease is degradation of the cartilaginous discal matrix. Whilst the mechanism by which this is mediated is unknown, in other situations where connective tissues are degraded degradation is the result of production of matrix-degrading enzymes by local connective tissue cells stimulated by cytokines, particularly the beta isoform of interleukin-1 (IL-1β). Included amongst these disorders is osteoarthritis (OA) of diarthrodial joints. OA has many similarities to the discal “degeneration” seen in mechanical back pain syndromes. In the current study, we have used a combination of in-situ techniques to establish if IL-1β is responsible for stimulating matrix degradation in the IVD. Methods: Using a combination of radioactive in-situ hybridisation (ISH) and competitive in situ zymography (ISZ) we have studied expression of IL-1β and IL-1R – its type 1 receptor (ISH) and matrix degradation (ISZ) in five diseased lumbar IVD taken at spinal fusion surgery and 10 cadaveric IVD (five normal and five diseased). The nucleus pulposus (NP) was separated from the annulus fibrosus and diced into 0.5cm cubes. Half the cubes (typically three) were fixed in formalin and processed into paraffin wax for ISH, and half were used for ISZ. For ISH, 5 μm sections of paraffin-embedded tissue were reacted with cDNA probes radiolabelled with 35S to 580 and 530 base segments of the IL-1β and IL-1R molecules. Hybridisation was disclosed using autoradiography. For ISZ, 50 μm vibratome sections were placed into wells on microscope slides precoated with gelatin. Sections were incubated for 10 days, half in culture medium and half in medium supplemented with human recombinant IL-1 receptor antagonist (IL-1Ra – an inhibitor of IL-1). Sections were photographed at daily intervals to detect evidence of gel degradation. Results: Chondrocytes within patient and cadaveric diseased but not normal discs expressed mRNA for both IL-1β and IL-1R. By ISZ, the same cells degraded gelatin. Degradation was inhibited by recombinant IL-1Ra. Conclusion: This study shows that chondrocytes of diseased discs express IL-1 and its receptor. The same cells produced matrix-degrading enzymes by a mechanism that can be inhibited by the IL-1 inhibitor IL-1Ra. IL-1 is a potential therapeutic target for the management of IV disc disease

Purposes of the study and background. Characteristics of muscle activity, represented by surface electromyography (EMG), have shown differences between patients with low back pain and healthy adults; how they relate to functional/clinical scales remains unclear. The purpose of the current study was to examine the correlation between frequency characteristics of EMG and patients' self-rated score of disability using continuous wavelet transform (CWT) analysis. Methods and Results. Fifteen patients with chronic mechanical low back pain (LBP) and 10 healthy adults were recruited. Patients completed the Roland-Morris Disability Questionnaire (RMDQ) and bilateral EMG activity was obtained from erector spinae at vertebral level L4 and T12. Subjects performed 3 brief maximal voluntary contractions (MVCs) of the back extensors and the torque was measured using a dynamometer. CWT was applied to the EMG signals of each muscle in a 200ms window centred around the peak torque obtained during the MVCs. The ratio (low/high frequencies) of the energy, the peak energy, and the frequency of the peak energy were calculated for each muscle and then averaged and correlated with the individual's RMDQ score. Patients had significantly lower peak power than the controls (p=0.04). Additionally, RMDQ positively correlated to the average ratio of energy (rho=0.71; p=0.01), meaning higher disability corresponded to a dominant distribution of energy in the lower-frequencies; but negatively correlated to the average frequency of peak energy (rho=-0.61; p=0.035), meaning lower frequency of peak energy corresponded to higher levels of disability. Conclusion. The current findings support anatomical evidence of changes in muscle fibre composition of back muscles in subjects with chronic LBP. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained