Objectives:. To establish the demand, referral pathways, utility and patient satisfaction of a physiotherapy led post operative spinal surgery review clinic. Methods:. From July 2014 to January 2015 a pilot physiotherapy led clinic was established. The following clinic data was collected: number of patients reviewed, surgical procedure, outcome of clinic assessment, numbers requiring further investigation, numbers requiring review in the consultant led clinic and adverse events. A patient satisfaction survey was also administered to all English speaking patients. Patients were asked to rate the ease of getting through to the service by phone, length of wait, time spent with the clinician, answers to questions, explanation of results, advice about exercise and return to activities, the technical skills of the clinician, their personal manner and their overall visit. Data was anonymised and inserted into an excel spreadsheet for analysis. Descriptive statistical analysis was undertaken. Results:. 28 patients were reviewed in the pilot clinic. 17 (61%) patients were reviewed and discharged. 11 (39%) patients required discussion with the consultant. The outcome was: Referral for further imaging: n=5 (18%), referral to other specialist: n=2 (6%), consultant led OPD clinic review n=4 (14%) and surgical review of wound n=1 (4%). 84% (n=21/25) of eligible patients completed a post operative satisfaction survey. 86% (n= 18/21) rated their overall visit as excellent. There were no adverse events reported. Conclusion:. The pilot clinic has informed the development of a permanent physiotherapy led post op clinic in the National Neurosurgical Spinal Service and demonstrates the value of interdisciplinary care in this population

Purpose. A Virtual Spinal Clinic (VSC) was set-up at a regional spinal referral centre to see if patient care could be improved through early advice to provide timely management, early onward referral, improve patient satisfaction and minimise chronicity. The clinic was based on the successful virtual model used throughout the country within orthopaedic fracture clinics. VSC is a Consultant led multi-disciplinary (MDT) clinic run by Advanced Practitioners (AP). Methods. A 3-month trial of the VSC was completed bi-weekly. Patients diagnosed with conservatively managed spinal fractures were referred from the on-call service. A management plan was devised by a Consultant Spinal Surgeon and communicated to patients by the AP via a telephone-call consultation where clinical advice and management could be discussed. Results. 23 clinics completed. 271 patient contacts. 216 reviewed virtually. Completed outcomes of VSC. 34.65% Discharged. 51.18% Routine appointment. 14.17% Urgent appointment. Conclusion. VSC successfully completed safe and timely assessments, management plans, telephone consultations and onward referrals for Greater Manchester patients with acute spinal fractures. Patients had earlier access to health professionals to provide advice, reassurance, complete onward referrals and safety-netting. Patient satisfaction improved, with patient reporting the telephone consultation was reassuring and allowed early return to previous function. VSC reduced patients waiting time for a follow-up appointment and reduced patients travel time across Greater Manchester. In the future, it is hoped that the 6-week follow-up telephone call service will be utilised more as VSC develops. No conflicts of interest. No funding obtained

Purpose of Study/Background. To identify whether patients were satisfied with the overall educational component of the specialist nurse (CNS)/occupational therapist (OT) led pre-operative assessment clinic in order to identify areas which required improvement. The pre-operative specialist nurse led clinic was set up in 2002. The aim was to provide high quality information to patients undergoing elective spinal surgery in order to manage expectations and optimise post-operative recovery. Initially the clinic was specialist nurse led however, in 2006 occupational therapy input was introduced in order to provide an increased depth of information in regard to function and activities of daily living post operatively. In addition this has allowed assistive equipment to be provided pre-operatively. The format of this clinic has enhanced the patient's journey by facilitating reduced length of stay and more timely discharge. Methodology. A questionnaire was forwarded to a random sample of two hundred patients who attended for pre-operative assessment in the twelve-month period between April 2014 & March 2015. Sixty questionnaires were returned (30% response rate). Results/Summary. Patients were asked 17 questions in total, 3 general, 6 regarding CNS and 8 regarding OT. The responses were rated ‘very good’; ‘good’ ‘average; ‘poor’. In the returned audits no ‘poor’ responses were recorded. Clarity of information given: Very Good-56%; Good-39%; Average-5%. Overall experience of pre-operative assessment: Very Good-66%; Good- 32%; Average-2%. Advice given by OT: Very Good-82%; Good-16%; Average-2%. Information given by CNS: Very Good-75%; Good-23%; Average-2%. Conclusions. The results indicate that the OT and CNS specialist education sessions are considered valuable by patients. We believe that we have achieved this through good team-working in a multidisciplinary setting. Patients who attend these clinics are often anxious regarding surgery, have un-realistic expectations in relation to what to expect post-operatively. A significant number of our patients are elderly and have multiple pathologies which we take into account. The education sessions link into our patient information leaflets which, expand on this allowing patients to clarify matters and ask questions. No Conflicts of Interest. No Funding Obtained

To determine factors such as age, sex and curve severity in patients with idiopathic scoliosis presenting for the first time to a spine deformity clinic. A prospective study at a regional spine clinic. Patients with idiopathic scoliosis presenting for the first time to the scoliosis clinic were entered into a database recording information such as age, symptoms, severity of scoliosis as measured by the Cobb angle (CA), spine rotation measured by Scoliometer, geographical region, person detecting the curve, neurological findings etc. The study period was from June 2008 to September 2009 inclusive. Fifty consecutive patients with all required information in the database were included in the analysis. All eligible patients were not entered due to logistical reasons. 13 males and 37 females, average age 13.96 (range 1 to 23). 68% were unhappy with the shape of their back, 48% presented with significant pain and 32% had both. The mother first saw the scoliosis in 52%, the rest were seen by either the patient, friends or doctors. 36 were single curves with a mean CA of 34 degrees ranging from 10 to 80 degrees. 52% of patients presented with a curve of 40 degrees or more. 14 had double curves. None of the patients were found to have any abnormal neurological findings. There are few epidemiological studies in the recent literature. This data was not previously available in our region and initial presentation with a severe curve is a worrying trend which triggered this study

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain. 56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met. 56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied. Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported

Background. Scoliosis is described as a lateral spinal curvature exceeding ten degrees on radiograph with vertebral rotation. Approximately 80% of scoliosis presentations are adolescent idiopathic scoliosis (AIS). Current management for AIS in the UK occurs in Surgeon or Paediatrician-led clinics and can be conservative or surgical. The musculoskeletal assessment and triage of AIS appears well-suited to an advanced physiotherapist practitioner (APP) skill set. The aim of this service evaluation was to scope, develop, implement and evaluate a four-month pilot of an APP-led AIS triage pathway. Method and Results. Spinal Consultant deformity and scoliosis clinics were scoped and observed. Clinic inclusion criteria and a patient assessment form was developed. An APP AIS clinic was set up beside a consultant led clinic. All patients assessed were discussed with a spinal surgeon. Consultant and APP agreement (% of total), waiting times, surgical conversion, and patient satisfaction were reviewed. A clinical competency package was developed for training and development of APPs. A total of 49 patients were seen (20 sessions). Waiting list reduced from 10 weeks to 6 weeks. 45%(n=22) of new patients seen were diagnosed with AIS, 27% (n=6) were directly listed for surgery. Consultant/ APP percentage agreement was high for Cobb angle measurement (82%), management plans (90%), and further diagnostic requests (94%). There were no adverse events and high patient satisfaction levels (n=20), (100% Very satisfied or satisfied) were reported. Conclusion. APP-led AIS clinics can provide similar levels of management and assessment as Spinal Consultants with improved waiting times and high levels of satisfaction. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose of the study. The purpose of this project was to evaluate whether OHEIs could facilitate student physiotherapy placement training in their educational outpatient clinics. Background. The National Health Service (NHS) is actively promoting Allied Health Professionals (AHPs) to have a greater role in supporting healthcare delivery. There are challenges to increasing AHP numbers and one of these is providing enough student training placements to meet demand. Methods. This evaluation used quantitative and qualitative methods. The OHEI clinical tutors and students collected activity data Anonymised questionnaires for physiotherapy students examining expectation were completed online before placement and an experience questionnaire after placement. Interviews and focus groups were conducted to investigate the experiences of stakeholders involved in the project. This included physiotherapy and osteopathy students, clinic tutors, and placement coordinators in OHEIs and physiotherapy HEIs. Results. Four universities with physiotherapy courses participated, and 37 students in 2 cohorts completed either five- or six-week placements at three OHEI clinics between April and August 2021. Cohort 1 expressed uncertainties about roles and integration in clinic and with patients. Concerns were addressed for Cohort 2 and physiotherapy student learning experiences were much better with 83% of physiotherapy students satisfied or very satisfied with their placement. Conclusion. The placement of physiotherapists in OHEI clinics is feasible. Careful expectation management is essential. Future sustainability is dependent upon managing costs to the OHEIs as it is unlikely placements will generate income. The learning environment could be made more reciprocal with time and experience leading to better understanding of the different professions and enhanced multidisciplinary working. Conflicts of interest: Dawn Carnes and Carol Fawkes are both trained osteopaths. Sources of funding: Health Education England grant to the Institute of Osteopathy (the professional association for UK osteopaths)

Background. A local authority approached us, for a cost-beneficial solution to their increasing low back pain referrals. We proposed developing a student-led clinic – an intervention delivered by students but supervised by clinicians. We then conducted scoping reviews on student-led clinics in the management of health conditions and on the self-management of back pain. The findings suggested that student-led self-management interventions for low back health should be feasible. The next step was to co-construct the intervention with key stakeholders. Co-Construction. A hybrid of Action Research and Design Science methodology was used to co-construct the intervention with five key stakeholder groups (council staff, managers and human resources, employee healthcare, students, and lecturers). Three rounds of focus groups explored the ‘problem’, the possible solutions, the process, and the content. Themes were taken from each of these focus groups and the similarities and differences were analysed. This analysis and subsequent synthesis with the evidence base created potential intervention models, which were discussed and refined with the stakeholder groups. Intervention. The proposed intervention is focused on providing evidence informed biopsychosocial support for work-relevant back pain, based on identifying obstacles and solutions to improve coping with back health at work. An onboarding workshop challenges positively their thinking around back pain and work. This is followed by up to three 1:1 sessions that support the individual to identify work-relevant back health goals and agree a plan to achieve them using techniques to facilitate behaviour change. Conclusion. The intervention is evidence informed and aims to address the prioritised needs of the stakeholders. Conflicts of interest. No conflicts of interest. Sources of funding. National Health Service Education

Purpose. The purpose of this study was to discover if student led clinics (SLC) are feasible delivery mechanisms for Low back pain (LBP) self-management support and to develop a service model. Background. LBP is the most commonly reported musculoskeletal disorder worldwide. The increasing service and workforce demands of LBP are challenging for providers and policy makers. self-management is appropriate for many people living with LBP yet guidance for self-management is lacking. One potential delivery mechanism is through SLC. These are ‘clinics’ run by students, supervised by clinicians. Methods and Results. A scoping review has found that SLC can be effective for supporting self-management of various long-term conditions and can provide cost benefits compared with traditional clinical services. In principle, their use for providing LBP services could have similar advantages as well as mitigating the clinical placement shortage. A further scoping review of self-management support for LBP was used to develop a model for student-led LBP clinics. The proposed model is a student led LBP supported self-management service. The service users will be triaged using the Psychosocial Flags Framework to identify obstacles to participation, followed by 1–6 sessions of self-management support comprising of; 1) empathetic listening and education to build a therapeutic relationship and to dispel LBP myths; 2) collaboratively setting meaningful goals; 3) imparting knowledge and skills to overcome the identified obstacles; 4) developing an evidence-informed plan for self-management, agreed with relevant stakeholders. Conclusion. Previous experience and the evidence-base suggest that SLC are feasible for delivering self-management support for LBP. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Background. Advanced spinal practitioner physiotherapists (ASPPs) assess and manage spinal referrals, as advocated by the National Low Back Pain Pathway in the United Kingdom. The ASPP pathway relies on multi-disciplinary team (MDT) meetings where potential surgically appropriate or complex cases can be discussed. Meetings were held with two different Consultant Spinal Neurosurgeons (total 2 meetings per month). The aim of this service evaluation was to assess MDT meeting outcomes and surgical listing. Methods. This retrospective service evaluation used routinely collected MDT meeting documentation between May 2019 and October 2021. Data was extracted by two ASPPs, and 20% checked by a third ASPP. Extracted data included: number of patients discussed, Consultant, reason for discussion, and outcome (surgical listing or other). Data was analysed by two ASPPs using pivot tables in Microsoft Excel and was reported using counts and percentages across month and year. Results. The majority of MDT discussions were for a surgical opinion (n=293, 25% clinician led, n=351, 30% patient led). Of these, 46% (n=135) of clinician surgical opinions were directly listed compared to 20% (n=70) of patient led discussions. Similar rates of consultant clinic review were seen between the two groups (22% and 32%), suggesting that the majority of patients discussed for surgical consideration were appropriate. 517 (45%) were discussed for management opinion. Conclusions. This evaluation demonstrates that a majority of cases (68%) identified by ASPPs for surgical opinion were either directly listed or had consultant clinic surgical review. The results and trends identified will guide future patient pathway development and ASPP training. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Aims. Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). Methods. UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion. The primary outcome is ‘treatment failure’ (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or ‘treatment success’ (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry. Cite this article: Bone Jt Open 2023;4(11):873–880

Aims. Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF). Methods. We retrospectively reviewed all AIS patients who had undergone PSF between January 2018 and January 2020 in a specialist tertiary spinal referral centre. All patients were assessed preoperatively in an anaesthetic clinic. Postoperative care was defined as ward-based (WB) or critical care (CC), based on the preoperative FEV1, FVC, major curve Cobb angle, and the planned number of instrumented levels. Results. Overall, 105 patients were enrolled. Their mean age was 15.5 years (11 to 25) with a mean weight of 55 kg (35 to 103). The mean Cobb angle was 68° (38° to 122°). Of these, 38 patients were preoperatively scored to receive postoperative CC. However, only 19% of the cohort (20/105) actually needed CC-level support. Based on these figures, and an average paediatric intensive care unit stay of one day before stepdown to ward-based care, the potential cost-saving on the first postoperative night for this cohort was over £20,000. There was no statistically significant difference between the Total Pathway Score (TPS), the numerical representation of the four factors being assessed, and the actual level of care received (p = 0.052) or the American Society of Anesthesiologists grade (p = 0.187). Binary logistic regression analysis of the TPS variables showed that the preoperative Cobb angle was the only variable which significantly predicted the need for critical care. Conclusion. Most patients undergoing posterior fusion surgery for AIS do not need critical care. Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care, and has a threshold value of 74.5°. Cite this article: Bone Joint J 2024;106-B(7):713–719

A Core Outcome Set (COS) for treatment of adolescent idiopathic scoliosis (AIS) is essential to ensure that the most meaningful outcomes are evaluated and used consistently. Measuring the same outcomes ensures evidence from clinical trials and routine clinical practice of different treatments can be more easily compared and combined, therefore increasing the quality of the evidence base. The SPINE-COS-AYA project aims to develop a gold standard COS which can be used internationally in research and routine clinical practice to evaluate the treatment (surgical and bracing) of AIS. In this qualitative study, the views of adolescents and young adults with AIS (10-25 years of age), their family members and healthcare professionals in a UK region were sought, via interviews, on treatment outcomes. Participants were purposively recruited from a variety of sources including NHS outpatient clinics and social media. Semi-structured interviews were analysed using thematic analysis. Key findings will be presented, to include potential core outcome domains identified by the different subgroups. The core outcome domains identified in this research programme will subsequently form part of an international consensus survey to agree a COS. In future, if the COS is used by healthcare staff and researchers, it will be easier for everyone, including patients and their families, to assess which treatment works best

Background. The national back pain pathway sets out the gold standard pathway for patients with back and radicular pain. To improve implementation we needed to understand current practice and identify divergences from the pathway. Objectives. 1) What patient is referred into the surgical clinic?. 2) What treatments had they tried?. 3) How many had spinal interventions. 4) Consider ways to improve the appropriateness of referrals. Method. 100 new patients attending the Spinal Orthopaedic Clinic from December 2018 to February 2019 were asked to complete a questionnaire asking about previous interventions and benefit gained. Symptoms and outcomes were recorded from the clinical entries and MRI's reviewed. Results. Over 90 had tried analgesics with only 60 reporting more than 50% benefit. Only 6 had tried neuromodulators all with poor results. 82 attended physiotherapy with 62 reporting some benefit. 84 tried exercises and 31 found it helpful whereas 17 had acupuncture and 8 of those reported benefit. 65 had consistent findings on their MRI and 31 elected to have an intervention. 8 were better, 22 wanted to self-manage and 4 went to other providers. Conclusion. 82% of our patients had tried analgesics and physical therapy before being referred to secondary care. Few opted to have an intervention and could possibly have been managed in a non-surgical clinic. If appropriate training and management is put into primary care settings, secondary care referrals could be reduced. Only 1/3 of the patients were right patient right place right time. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose & Background. The STarT Back risk-stratification approach uses the STarT Back Tool to categorise patients with low back pain (LBP) at low, medium or high-risk of persistent disabling pain, in order to match treatments. The MATCH trial (NCT02286141) evaluated the effect of implementing an adaptation of this approach in a United States healthcare setting. Methods. This was a pragmatic cluster randomised trial with a pre-intervention baseline period. Six primary care clinics were pair-randomised, three to an intensive stratified care quality improvement intervention and three as controls. LBP patients were invited to provide outcomes two weeks after their primary care visit, and two and six months later. Primary outcomes were physical function (RMDQ) and pain (0–10 NRS), and secondary outcomes including healthcare use and treatments provided received. Analysis was intention-to-treat. Results. Patient outcomes were obtained from intervention (n=690) and control (n=864) clinics. At six months between-group differences in adjusted mean change scores did not significantly favour stratified care for RMDQ; 0.50 (95%CI −0.55, 1.55) or pain NRS 0.13 (95%CI −0.37, 0.63). There were no significant between group differences in any secondary patient outcome. Process data showed that the STarT Back tool was used with 47% of LBP patients in the intervention clinics but there was no differences in the treatments provided. Conclusions. Implementation of a LBP stratified care approach in this United States healthcare setting showed moderate use of the STarT Back tool, but no change in treatments received by patients, and no benefits on patient outcomes. Conflicts of interest: None. Sources of funding: Funding for this trial was provided by the Patient Centered Care Research Institute (“Evaluation of a Patient-Centered Risk Stratification Method for Improving Primary Care for Back Pain”: Contract #398) and by the National Center for Complementary and Integrative Health/NIH (“Implementing Evidence-Based Treatments for Persistent Back Pain into Primary Care”: Grant #R21AT0007326). Martin Levine, Diane Piekara, and Pam Rock received support to participate in the quality improvement activities from Group Health. Nadine Foster and Jonathan Hill were supported through an NIHR Research Professorship (NIHR-RP-011-015) to Nadine Foster. Nadine Foster is an NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the Patient Centered Care Research Institute, NIH, NHS, the NIHR or the Department of Health

Purpose. To investigate sociodemographic and clinical characteristics in patients operated for lumbar disc herniation in public and private hospitals, and evaluate whether selection for surgical treatment were different across the two settings. Methods and results. A cross-sectional multicenter study of patients who underwent a total of 5308 elective surgeries for lumbar disc herniation at 41 hospitals. Data were included in the Norwegian Registry for Spine Surgery (NORspine). Of 5308 elective surgical procedures, 3628 were performed at 31 public hospitals and 1680 at 10 private clinics. Patients in the private clinics were slightly younger, more likely to be man, have higher level of education, and more likely to be employed. The proportions of disability and retirement pension were more than double in public as compared to private hospitals. Patients operated in public hospitals were older, had more obesity and co-morbidity, lower educational level, longer duration of symptoms, and sick leave and were less likely to return to work. Patients operated in public hospitals reported more disability and pain, poorer HRQol and general health status than those operated in private clinics. The differences were consistent but small and could not be attributed to less strict indications for surgical treatment in private clinics. Conclusion. Indications for surgical treatment of lumbar disc herniation appear to be similar in public and private hospitals. Patients operated in private clinics seem to be handled more effectively. They were younger, healthier and had more socioeconomic and lifestyle attributes, known to be predictors more favorable outcomes after surgery

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We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

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Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

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To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

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Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.