Diagnostic imaging in LBP is controversial. Concerns relate to costs and “creating potential barriers to recovery”.

Methods: All GPs in north Bristol (population 250,000) submitted every non-emergency referral for LBP+/−sciatica to our office, as a “single point of entry” clinic. 1301 patients have been assessed, 1283 with MRI screening.

We calculated proportions of MRI diagnoses and treatment pathways, and compared these with routine care (the pre-existing service, having comparable protocols, other than MRI screening.

Results: Summary of MRI diagnoses - potential surgical spine pathology 519(40.5%) (disc prolapse=295, stenosis=148, spondylolisthesis=49, other=27); serious pathology (tumours, aortic aneurysms) 12(0.94%); spondylosis 681(53%); no degenerative change- 71(5.5%).

Only 149(11.6%) of patients needed follow-up in clinic (30–58% in routine care). Overall, 637(49.6%) patients were managed in primary care, and 646(50.4%) were referred to secondary care, including 161(12.5%) referred for surgery, comparable to routine care (12–16% surgery), and 406(31.6%) patients referred to consultant pain physicians.

Discussion: In the new service, time from referral to diagnosis/treatment planning reduced from 12–16 weeks to three weeks. MRI screening did not increase referrals for surgery. Costs were minimised by leasing downtime on NHS scanners, with dedicated lumbar spine sessions leading to increased scans per hour. Very low follow-up rate further reduced costs.

The use of MRI as a tool to advise LBP patients on the spectrum of management options is arguably the way of the future. We would however, not recommend this without subsequent clinical review by an experienced clinician, including a discussion about the relevance of the findings.

Conflicts of Interest: None

Source of Funding: None

Introduction: Impaired muscle function due to pain or inactivity may contribute to poor outcome following disc surgery. This study investigated the effects of postoperative exercise on pain, disability and spinal function in patients undergoing microdiscectomy.

Methods: Volunteers who gave informed consent (65M/26F) were blindly randomised to Exercise and Control groups. All patients were assessed the week before surgery. Posture and range of motion were measured using the 3-Space Fastrak, and back muscle fatigue was evaluated during the Biering-Sorensen test from changes in median frequency of the electromyographic signal. In 42 patients, intra-operative muscle biopsies were obtained. Four weeks after surgery, patients underwent a second functional assessment, after which the Exercise group began a 4-week exercise programme. Further assessments were performed at 2, 6, 12, 18 and 24 months after surgery. Pain, disability and psychological status were evaluated throughout using appropriate questionnaires.

Results: Marked type II fibre atrophy was evident at surgery, and this was reflected in pre-operative measures of median frequency. At 4 weeks, both groups showed significant improvements in pain, disability and psychological status but limited improvements in function. At 2 months, the Exercise group showed further improvements in pain, disability and psychological status, increased ranges of motion, and improved fatigability. Increases in initial median frequency in the fatigue test suggested fibre hypertrophy. Further improvements in the Control group generally achieved significance 6–12 months after surgery.

Conclusions: Surgery is effective in improving pain, disability and psychological status. Recovery of muscle function after surgery is naturally slow but can be accelerated by post-operative exercise.