Aims. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

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

Background and study purpose. Low mood and distress are commonly reported with by people with persistent musculoskeletal pain and may be mislabelled as ‘depression’. In order to understand how pain-related distress is conceptualised and managed in primary care consultations, we explored understanding of pain-related distress and depression from the perspectives of people with persistent musculoskeletal pain and general practitioners (GPs). Method and results. Semi-structured interviews with 21 GPs and 21 people with persistent musculoskeletal pain were conducted. The majority of people with pain had back pain (15/21). Data were analysed thematically using constant comparison techniques. Participants described challenges distinguishing between distress and depression in the context of persistent pain but described strategies to make this distinction. Some people with pain described how acceptance of their situation was key, involving optimism about the future and creation of a new identity. Some GPs expressed ‘therapeutic nihilism’, with uncertainty about the cause of pain and thus how to manage people with both pain and distress, whilst GPs who could identify and build on optimism with patients described how this could help the patient to move forwards. Conclusion. This study offers a model for the primary care consultation with patients presenting with pain-related distress. GPs should recognize the impact of pain on the patient, support the person in acceptance of the pain, explore how the person feels about the future, encourage optimism, and support self-management strategies. Conflicts of Interest: No conflict of interests. Sources of funding: This study was funded by Versus Arthritis – grant number: 22454; Carolyn A Chew-Graham is part-funded by NIHR Applied Research Collaboration (ARC) West Midlands

Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347

Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

Background. Embodiment- and distraction-based approaches to immersive virtual reality (IVR) show promise in treating persistent low back pain (PLBP). However, which approach is more effective is unclear. This study aims to evaluate the impact of distraction- and embodiment-based IVR on pain processing and patient-reported outcome measures in PLBP. Method. Individuals with PLBP were randomised to receive eight sessions of either distraction- or embodiment-based IVR over two weeks. Outcome measures were evaluated at baseline and after the eighth session. Pain processing was evaluated using conditioned pain modulation (CPM) and temporal summation (TS). Results. Three participants (n=2 embodiment, n=1 distraction) have completed all eight IVR sessions. Preliminary results indicate a decrease from pre to post-intervention in Numerical Pain Rating Scale score (pre: 5/10, 6/10, 5/10; post: 2/10, 5/10, 2/10) and Pain Catastrophising Scale score (pre: 34/52, 11/52, 38/52; post: 11/52, 8/52, 12/52), with no clear trend in other self-reported measures (Hospital Anxiety and Depression scale, Oswestry low back disability questionnaire, fear-avoidance beliefs questionnaire, Tampa scale of kinesiophobia). Preliminary results suggest a potential increase in NPRS absolute values from pre- to post-intervention in CPM (pre: -2.7, -2.3, -2.0; post: -3.3, -2.0, -4.3) and TS (pre-1.2, 2.5, 2.4; post: 1.4, 2.5, 3.1). Conclusion. Eight sessions of IVR may reduce pain severity and pain catastrophising in people with PLBP and may increase the efficacy of endogenous pain modulatory systems. Data collection is ongoing to compare the effect of distraction- and embodiment-based IVR. Conflicts of Interest. There are no conflicts of interest. Sources of Funding. This project is funded by the Saudi Arabia Cultural Bureau

Background. Depression, anxiety, catastrophising, and fear-avoidance beliefs are some of the so-called “yellow flags” that predict a poor outcome in back patients. Many surgeons have difficulty assessing yellow flags, perhaps due to the complexity of existing instruments and time constraints during consultations. We developed a brief tool to allow the systematic evaluation of core flags. Methods. Data from 4 questionnaires (ZUNG depression (N=399); Hospital Anxiety and Depression Scale (Anxiety-subscale) (N=308); Pain Catastrophising (N=766); Fear Avoidance Beliefs (N=736)) were analysed to identify the respective single item that best represented the full scale score. The 4 items formed the “Core Yellow Flags Index” (CYFI). 1'768 patients completed CYFI and a Core Outcome Measures Index (COMI) preoperatively, and COMI 3 and 12mo later (FU). Results. The individual flag items correlated with their corresponding full-length questionnaires: 0.71 (depression), 0.81 (catastrophising), 0.77 (anxiety), 0.83 (fear avoidance beliefs). Cronbach's α for the 4 items was 0.79. Structural equation modelling revealed that CYFI explained a unique proportion of the variance in COMI at 3 months' FU (β=0.23, p< 0.001) and also at 12 months FU (β=0.20, p< 0.001). Conclusion. The 4-item CYFI proved to be a simple, practicable tool for routinely assessing key psychological attributes in spine surgery patients; it made a relevant contribution in predicting postoperative outcome. CYFI's items were similar to those in the “STarTBack screening-tool”, used in primary care to predict back pain chronicity, further substantiating its validity. Its wider use may help improve the accuracy of predictive models derived using spine registry data. No conflicts of interest. No funding obtained

Purpose and background. There is lacking evidence about the prognostic role of anxiety as prognostic in acute low back pain patients. The objective of this study was to determine whether patients with acute low back pain (ALBP) are at risk to develop chronic low back pain (CLBP) and pain-related disability after 12 weeks due to high anxiety levels. Methods and results. An observational multi-centre study was conducted in primary physiotherapy care with measurements at baseline and at 12 weeks including known prognostic factors and psychological candidate predictors for CLBP. Two hundred and four participants completed both assessments of which 51 and 54 were classified as having less than 50% decrease in pain and pain-related disability, respectively. For pain, the final model contained higher pain intensity, longer pain duration, depression symptoms, and state anxiety with explained variance 0.30, sensitivity 0.74, specificity 0.82, Likelihood Ratio 4.1 (95% CI 2.0 to 6.1) and Area Under the Curve 0.78 (95% CI 0.70 to 0.85). For pain-related disability, trait anxiety, depression symptoms, and state anxiety contributed independently to the prediction with the model's explained variance of 0.19, sensitivity 0.78, specificity 0.78, Likelihood Ratio 3.0 (95% CI 2.0 to 4.5), and Area Under the Curve 0.73 (95% CI 0.65 to 0.81). Conclusion. State anxiety in patients with ALBP is an independent predictor of CLBP at 12 weeks after baseline in primary physiotherapy care and should be measured, in addition to known prognostic factors and depression symptoms, in order to intervene and potentially decrease duration of complaints. No conflict of interest. No funding obtained

Purpose and background. Acute and chronic spinal pain are major causes of disability, and many patients use analgesics to treat their pain. However, increased use of analgesics, particularly prescription opioids have the potential to be overused and cause dependence. Psychological factors such as stress, anxiety, depression, pain acceptance, pain catastrophising and alexithymia influence both the pain response and analgesic use, yet to date no studies have explored these variables in spinal pain patients. Therefore, the aim of this study is to assess the nature, prevalence and correlates of analgesic dependence among patients with acute or chronic spinal pain. Methods and results. Patients over the age of 18 attending outpatient services at the Royal Derby Hospital with complaints of either acute or chronic spinal pain and currently using analgesics to treat their pain completed the Current Opioid Misuse Measure, the Depression, Anxiety and Stress Scale-21, the Chronic Pain Acceptance Questionnaire-8, the Pain Catastrophising Scale, the Toronto Alexithymia Scale-20, and the Leeds Dependence Questionnaire, a measure of analgesic dependence. Preliminary findings from 52 patients (16 males and 36 females) with chronic spinal pain ranging from 23–88 years old, show that greater pain catastrophising is a significant predictor of analgesic dependence (t = 2.74, df = 51, p = 0.009). Conclusion. The study findings can inform the development of appropriate interventions targeting pain catastrophising to prevent and/or treat analgesic dependence, as well as contributing to potential future research on the understanding of tapering spinal pain patients off analgesic medication. No conflicts of interest. No funding obtained

Background. Social context may be important in chronic pain. One focus is reactions to pain between persons with LBP and their partners. Researchers have investigated partner reactions and found influences on pain levels and psychological outcomes, but little is known about factors underpinning these reactions. Aim. To investigate the associations of relationship quality and perceived partner responses with LBP intensity and disability. Method. Participants with partners (n=174) in a cohort study of LBP in primary care were included. Data on pain intensity, disability (RMDQ), perceptions of negative or solicitous partner responses (MPI), relationship quality (RDAS) and depression and anxiety (HADS) was collected. Results. Consensus (e.g. agreement about affection and sex) and satisfaction (frequency of arguments/disagreements) were significantly associated with pain intensity (p 0.01 and p 0.02). Solicitous partner responses (e.g. providing comfort, physical assistance) were significantly associated with patient disability (p 0.04). These significant associations only became apparent when depression was entered into the model, suggesting effect modification. Stratification by depression revealed associations between consensus and pain among those with high depression levels (p 0.04) and associations between solicitousness and disability in those with low depression levels (p 0.01). Overall, the models accounted for 14-17% of the variance in pain intensity and 26-29% of the variance in disability. Conclusion. Results show associations of solicitousness, satisfaction and consensus with pain intensity and disability. However the effect varies by the presence of depression. Further research should investigate further the pathway of relationship quality, depression and pain

Purpose of the study and background. In the majority of low back pain (LBP) patients a definitive cause for back pain cannot be established; consequently, many patients report feeling uncertain about their diagnosis. They also experience pain-related guilt, which can be divided into: social guilt, managing pain guilt and verification of pain guilt. This study aimed to test a theoretical (causal) model, which proposed that diagnostic uncertainty leads to pain-related guilt, which leads to depression, anxiety and finally to disability. Summary of the methods used and the results. Structural equation modelling was employed to test this model on 438 participants with LBP. The model demonstrated an adequate to good fit with the data. Diagnostic uncertainty predicts all three types of guilt. Verification of pain guilt predicts disability, managing pain guilt predicts anxiety, while social guilt was the strongest predictor of negative outcomes, predicting depression, anxiety and disability. Conclusion. These preliminary findings demonstrate that diagnostic uncertainty and pain-related guilt are predictors of outcomes in LBP. They are important in relation to at least two aspects: firstly, psychological interventions produce small to moderate and mostly short term effects. This could be due to poorly designed and inconsistent theoretical models, which do not consider subcomponents of overarching psychological constructs such as depression. Secondly, they use heterogeneous groups of patients. Our model examined guilt, a known symptom of clinical depression but poorly understood within the context of pain. It also classified LBP participants according to their diagnosis-related beliefs. This should enable a greater understanding of how LBP patients differ and could help adjust consultations, reassurance given and treatment accordingly. This abstract reports preliminary findings of a study that has not been submitted or published in another journal or meeting. Conflicts of interest: No conflicts of interest. Source of Funding: The study was partly funded by the Pain Relief Foundation and British College of Osteopathic Medicine; however they had no involvement in the study design, data collection, data analysis and manuscript preparation

Purpose of the study and background:. Identifying mechanisms that mediate recovery is imperative to improve outcomes in low back pain (LBP). Qualitative studies suggest that guilt may be such a mechanism, but research on this concept is scarce, and reliable instruments to measure pain-related guilt are not available. We addressed this gap by developing and testing a pain-related guilt scale (PGS) for people with LBP. Summary of the methods used and the results:. Two samples of participants with LBP completed the scale and provided data on rates of depression, anxiety, pain intensity and disability. Three factors were identified using exploratory factor analysis (n=137): ‘Social guilt’ (4 items) relating to letting down family and friends; ‘Managing condition/pain guilt’, (5 items) relating to failing to overcome and control pain; and ‘Verification of pain guilt’, (3 items) relating to the absence of objective evidence and diagnosis. This factor structure was confirmed using confirmatory factor analysis (n=288), demonstrating an adequate to good fit with the data (AGFI= 0.913, RAMSEA= 0.061). The PGS subscales positively correlated with depression, anxiety, pain intensity and disability. After controlling for depression and anxiety the majority of relationships between the PGS subscales and disability and pain intensity remained significant, suggesting that guilt shared unique variance with disability and pain intensity independent of depression and anxiety. High levels of guilt were reported by over 40% of patients. Conclusion:. The findings suggest that pain-related guilt is common and is associated with clinical outcomes. Prospective research is needed to examine the role of guilt as a predictor, moderator and mediator of patients' outcomes

Statement of the purposes of the study and background:. Low back pain (LBP) is the leading cause of disability worldwide, and greater understanding of mechanisms leading to increased disability in LBP is necessary. Pain-related guilt and in particular social guilt (one type of pain-related guilt) has recently been linked to greater depression, anxiety and disability in LBP. Research has also shown that greater acceptance of pain is associated with less pain intensity, depression, pain-related anxiety and disability, and with greater daily activity and overall wellbeing in chronic pain patients. The current study aim was to understand the relationship between pain-related guilt and pain-related acceptance in LBP. Summary of the methods used and the results:. The study examined the relationship between pain-related guilt and pain-related acceptance in a sample of 287 LBP patients. A series of hierarchical multiple regression analyses were conducted in which known correlates of pain-related acceptance (pain intensity, disability, depression and anxiety) were controlled for, with the objective of testing whether pain-related guilt explains any unique variance in pain-related acceptance. Social guilt was the strongest predictor of reduced pain-related acceptance in all analyses. Conclusion:. The findings highlight the role of social guilt in pain-related acceptance and they enable a better understanding of psychological factors associated with acceptance of pain. The study was cross-sectional, thus the direction of these relationships should be further examined using longitudinal designs

Purpose of the study and background. Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem. Summary of the methods used and the results. Patients (N=68) endorsed and subsequently recalled pain, illness, depression and neutral stimuli. They also provided measures of pain, diagnostic status, mood and disability. Both groups exhibited a recall bias for pain stimuli, but only the group with diagnostic uncertainty additionally displayed a recall bias for illness-related stimuli. This bias remained after controlling for depression and disability. Sensitivity analyses using grouping by diagnosis/explanation received supported these findings. Higher levels of depression and disability were found in the group with diagnostic uncertainty, but levels of pain intensity did not differ between the groups. Conclusion. Although the methodology does not provide information on causality, the results provide evidence for a relationship between diagnostic uncertainty and recall bias for negative health-related stimuli in chronic LBP patients. This abstract has been submitted to a journal, but it has not been published yet. Conflicts of interest: No conflicts of interest. The study was partly funded by the Pain Relief Foundation and British College of Osteopathic Medicine; however they had no involvement in the study design, data collection, data analysis and manuscript preparation

Background. Being involved in litigation is associated with poor outcomes, higher levels of pain, disability, catastrophising, fear-avoidance and other psychological factors. Poor access to treatments can contribute to chronicity of symptoms and poor outcomes, especially in patients involved in litigation with a longer time since the accident. Purpose. To examine the relationship between time since the accident, access to treatments and current psychological variables. Methods. Eleven patients completed the Pain Catastrophising Scale, Tampa Scale for Kinesiophobia, Zung Depression Inventory, Modified Somatic Perceptions Questionnaire as well as details about the accident, working status and recalled access to treatments. The results were analysed qualitatively and quantitavely. Results. The mean time since the accident was 32 months and the mean measures are: ZDI (41.9±9.3), PCS (33.3±9.4), TSK (47.5±9.2), MSPQ (15±8.4). Eight subjects are not currently working and three are working part-time. There was a positive correlation between time since the accident and depression (r=0.679) and MSPQ (r=0.547) but not for other variables. Average sequence of recalled treatments is outlined. Conclusion. Our results indicate that measures of depression and somatic perceptions keep increasing with time whereas catastrophising and kineshiophobia are relatively constant in a small group of litigants with spinal pain. The recalled treatments reflect a focus on invasive treatments with little long-term positive outcome and only one patient receiving the recommended combined physical and psychological programme. I can confirm that this abstract has not previously been published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Source of funding: No funding obtained

Background. Patients with low back-related leg pain (LBLP) can present with neuropathic pain; it is not known but is often assumed that neuropathic pain persists over time. This research aimed to identify cases with neuropathic pain that persisted at short, intermediate and longer-term time points, in LBLP patients consulting in primary care. Methods. LBLP patients in a primary care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible neuropathic pain) at baseline, 4-months, 12-months and 3-years. S-LANSS scores and percentages of patients with score of ≥12 are described at each time-point. Multiple imputation was used to account for missing data. Results. At baseline, 48.3% (293/606) of patients presented with neuropathic pain, 25.0% (94/376) at 4-months, 22.6% (79/349) at 12-months and 21.6% (58/268) at 3-years. A small proportion (6.6%) scored ≥ 12 at all four time-points. Those who scored ≥ 12 at baseline and 4-months reported higher disability (RMDQ (0–23) 15.2) and depression scores (HADS (0–21) 8.6), and lower pain self-efficacy (PSEQ (0–60) 27.2), compared to those with neuropathic pain at one other time-point at most. Conclusion. Few LBLP patients in primary care present with long-term persistent neuropathic pain. Patients with neuropathic pain at baseline and short-term follow-up present with greater morbidity in terms of disability, depression and lower confidence to manage their pain. This is important because these patients may benefit the most from early intervention using neuropathic pain medication. These findings will inform research investigating potential prognostic indicators of persistent neuropathic pain. Conflicts of interest: None. Sources of funding: Support for SA Harrisson, a National Institute for Health Research (NIHR) Clinical Doctoral Fellow and NE Foster, an NIHR Senior Investigator, was provided by an NIHR Research Professorship awarded to NE Foster (NIHR-RP-011-015). K Konstantinou is supported by a Higher Education Funding Council for England/ NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Purpose of study and background. Neuropathic pain is a challenging pain syndrome to manage. Low back-related leg pain (LBLP) is clinically diagnosed as either sciatica or referred leg pain and sciatica is often assumed to be neuropathic. Our aim was to describe the prevalence and characteristics of neuropathic pain in LBLP patients. Methods. Analysis of cross-sectional data from a prospective, primary care cohort of 609 LBLP patients. Patients completed questionnaires, and received clinical assessment including MRI. Neuropathic characteristics (NC) were measured using the self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (SLANSS; score of ≥12 indicates pain with NC). Results. 52% of the patients diagnosed with sciatica and 39% of those diagnosed with referred leg pain presented with pain with NC. Irrespective of LBLP diagnosis, patients with NC reported significantly worse leg pain (mean 5.8 vs 4.7), back pain intensity (0.0 vs 0.0), disability (RMDQ 15.2 vs 12.4), high risk of persistent disabling pain (47.5% vs 31.5%), depression (HADS 7.3 vs 5.4) and anxiety (8.9 vs 6.7), compared to patients without NC. Sciatica patients with NC presented with higher leg pain (6.0 vs 4.8) and disability but less anxiety (8.6 vs 10.2) and depression compared to patients with referred pain with NC. Conclusion. LBLP patients with NC present with more severe pain, disability and psychological morbidity, but these characteristics differ according to clinical diagnosis, suggesting potential subgroups. The data will inform future research on the clinical course and prognosis of these patients. No conflicts of interest. Sources of funding: Support for SA Harrisson, a National Institute for Health Research (NIHR) Clinical Doctoral Fellow and NE Foster, an NIHR Senior Investigator, was provided by an NIHR Research Professorship awarded to NE Foster (NIHR-RP-011-015). K Konstantinou is supported by a Higher Education Funding Council for England/ NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Background and purpose of study:. Chronic back pain is a complex and poorly understood condition incorporating sensory, cognitive and emotional elements. Research demonstrates a strong association between chronic back pain and cognitive and non-cognitive factors such as anxiety, depression, fear-avoidance and self-efficacy. However, until very recently, the way in which chronic back pain sufferers process their emotions was largely unknown. To this end, we conducted two case-control studies using a between-groups correlational design to investigate the relationship between chronic back pain and emotional processing. Methods and results:. In study 1, 55 chronic back pain sufferers and 55 pain-free individuals were administered the Emotional Processing Scale (EPS) to determine whether chronic back pain sufferers process their emotions differently from pain-free individuals. In study 2, 32 CBP sufferers and 27 pain-free individuals were administered the EPS, PHQ-9 and the GAD-7 to further test if chronic back pain is associated with altered emotional process and whether anxiety and depression may play a role in this relationship. Conclusion:. Our studies demonstrate that altered emotional processing and regulation are strongly associated with chronic back pain. Prospective studies are necessary before it can be ascertained whether this relationship is causative or as a consequence of chronic back pain. However, our results are in line with a recent prospective neuroimaging study, which demonstrates that chronification of low back pain shifts brain representation from nociceptive to emotional circuits. It is therefore critical that clinicians in the field of musculoskeletal care consider the role of emotional processing in their patients' evaluation and management

Purpose of the study and background. An integrated rehabilitation programme was developed and found feasible taking into account the existing evidence base, appropriate theories, and patient and public involvement. The integrated programme encompasses inpatient activities supported by a multidisciplinary team, and integration of knowledge, skills and behaviours in the patient's everyday life. The aim of this trial was to compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain (CLBP). Methods and Results. Comparison of two parallel rehabilitation programmes in a randomised controlled trial including 165 patients with CLBP. The integrated rehabilitation programme comprised an alternation of in total three weeks of inpatient stay and in total 11 weeks of home-based activities. The existing rehabilitation programme comprised a four-week inpatient stay. Primary outcome was changes in disability (Oswestry Disability Index). Secondary outcomes were changes in pain, pain self-efficacy, health related quality of life and depression. Outcomes were collected at baseline and 26-week follow-up. Disability decreased −5.76 (95%CI; −8.31, −3.20) for the integrated programme and −5.64 (95%CI; −8.45, −2.83) for the existing programme. The adjusted difference between the two programmes was −0.28 (95%CI; −4.02, 3.45). No statistically significant difference was found in any of the secondary outcomes. Conclusion. The results of the trial were consistent, showing no significant differences in patients' outcomes when comparing an integrated rehabilitation programme with an existing programme. Conflicts of interest: None. Sources of funding: Aarhus University, The Danish Rheumatism Association and Familien Hede Nielsens Fond

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.