Aims. The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB. Methods. A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis. Results. The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay. Conclusion. Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120–126

Aims

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

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

Introduction. Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document. Materials and Methods. Between 1/01/2009 and 15/07/2010, all spinal blocks done under care of three spinal surgeons (LB/NC/AAC) were reviewed. Images revisited on PACS for confirmation. We reviewed 229 patients (included single & two levels nerve root blocks, facet joint and lysis blocks). Data were collected with regard to radiation dose, screening times, third-quartile values used to establish DRLs, IR(ME) documentation and PACS fluoroscopic image documentation. Results. Third quartile single level NRB DAP (Dose area product) was 111.5 cGyCm2. Single level NRB screening time was mean-0.13, third quartile-0.2 min. Nerve specific dosimetry included L5 nerve (0.2 min; 119cGyCm2) and S1 nerve (0.2 min; 118.7cGyCm2). Mean ‘Click: Block ratio’ (last click for PACS/Block) was 22.4 (SD=7.05, range 10 to 48). Local fluoroscopic documentation was 87.2%. Conclusions. There are no national standards in radiation dosimetry for diagnostic spinal blocks. We recommend that all spinal units in the UK should evaluate their own DRLs to help establish national guidelines for fluoroscopy-guided spinal procedures. Representative fluoroscopic image documentation on PACS was 87% locally. It is a joint responsibility of radiographer & operating surgeon to make it 100% to reduce medicolegal risks

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 and background:. Sacroiliitis identified by MRI is considered as a keystone in the diagnosis of spondyloarthritis. To reduce the number of unnecessary MRI scans it would be ideal if sacroiliac (SI) joint pain provocation tests could be used to identify patients at risk of having sacroiliitis. The aim of the current study was to investigate the diagnostic value of three pain provocation SI-joint tests for sacroiliitis identified by MRI. Methods:. Patients (n=454, mean age 32 years, 54% women) without clinical signs of nerve root compression were selected from a cohort consisting of patients with persistent low back pain referred to an outpatient spine clinic. Data from the Gaenslen's Test, Thigh Thrust Test and Long Dorsal Sacroiliac Ligaments Test and sacroiliitis identified by MRI were analysed. Results:. The prevalence of SI-joints with sacroiliitis was 5%. In the whole study group, only the Thigh Trust Test was associated with sacroiliitis, ROC area 0.58 (95% CI 0.51–0.65), sensitivity 31% (18–47) and specificity 85% (82–87). In men, sacroiliitis was associated with all three SI joint tests and multitest regimens, with the greatest ROC area found for ≥ 1 positive out of 3 tests, (0.68 (0.56–0.80)), sensitivity 56% (31–79) and specificity 81% (77–85). In women, no significant associations were observed between the assessed SI joint tests and sacroiliitis. Conclusions:. Only in men were the performed SI-joint tests found to be associated with sacroiliitis identified by MRI. Although, the diagnostic value was limited, the results indicate that the use of SI joint tests for sacroiliitis may be optimised by gender-separated analyses

Introduction. Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Materials and Methods. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated. Results. There were 81 pyogenic, 16 tuberculous and 28 postoperative spinal infections. The mean age was 58.4 years (range, 19 to 88 years). There were 71 male and 54 female patients. There were 64 lumbar and 26 thoracic infections. Two level and multi-level spinal infections involving more than two segments occurred in 30 patients. Of sixty positive microbiology yields, the most common organism was methicillin sensitive staphylococcus aureus (n-23) followed by Streptococcal, E Coli and Coagulase negative staphylococcal and Pseudomonas infections. Second biopsy (done when first biopsy negative) was only positive in two patients. Conclusions. Annual incidence of de novo spinal infection was 48 (pyogenic-40, tuberculous-8). The most frequently isolated pathogen was Staphyloccus aureus. Multi-level infection, diabetic patients, resistant TB and postop infection in elderly patients constituted the ‘difficult to treat’ group in our experience. An algorithm for the diagnostic work-up and management of spinal infections is proposed

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making. Retrospective cohort analysis. 120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88). We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making. Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment. Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected

Purpose. Distinguishing between sequestered disc fragments and tumours remains a diagnostic challenge, but one of paramount importance given the surgical management of these two clinical entities varies dramatically. Methods. Our experience over the last 3 years in managing this clinical challenge was analyzed. Patients referred to the regional neurosurgical unit for evaluation of possible spinal tumours whose imaging and clinical findings were atypical, were prospectively identified and the medical notes, operative records and MR imaging reviewed. Results. This is the single largest series of patients presenting as tumors that were later determined to be sequestered disc fragments. 17 patients(8 female and 9 male) were identified. The median age was 54 years (range 35-77) and the mean follow up time 20 months. The most common location (16/17) for discs mimicking tumours in our series was in the lumbar spine. The major differential diagnosis was of nerve sheath tumours, followed by metastasis. The signal characteristics of the lesions and contrast enhancement were variable. 35% of patients had the lesion surgically excised and the diagnosis of intervertebral disc made intraoperatively or on histology. The remainder were monitored clinically and with MR imaging, and required no surgical intervention in the follow up period. The features that favoured a diagnosis of disc rather than tumour included a rapid onset of symptoms and abatement of pain with time. Radiologically, sequestered disc was more likely if the lesion demonstrated contiguity with the disc space, the presence of other degenerate discs, no foraminal exit widening, and the absence of central enhancement. Conclusion. Urgent surgery is not mandatory and in our series a “watch and wait” approach was utilized safely. When atypical clinical and imaging findings are present in patients referred for management of spinal tumours, sequestered disc fragments should be considered as a possibility

Background:. Identification of nerve root involvement (NRI) in patients with low back-related leg pain (LBLP) can be challenging. Diagnostic models have mainly been developed in secondary care with conflicting reference standards and predictor selection. This study aims to ascertain which cluster of items from clinical assessment best identify NRI in primary care consulters with LBLP. Methods:. Cross-sectional data on 395 LBLP consulters were analysed. Potential NRI indicators were seven clinical assessment items. Two definitions of NRI formed the reference standards: (i) high confidence (≥80%) NRI clinical diagnosis (ii) high confidence (≥80%) NRI clinical diagnosis with confirmatory magnetic resonance imaging (MRI) findings. Multivariable logistic regression models were constructed and compared for both reference standards. Model performances were summarised using the Hosmer-Lemeshow statistic and area under the curve (AUC). Bootstrapping assessed internal validity. Results:. NRI clinical diagnosis model retained five items. The model with MRI in the reference standard retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests, neurological deficit (myotome, reflex or sensory). NRI clinical diagnosis model was well calibrated (p=0.17) and discrimination was AUC 0.96 (95%CI: 0.93, 0.98). Performance measures for clinical diagnosis plus confirmatory MRI model showed good discrimination (AUC 0.83, 95% CI: 0.78, 0.86) but poor calibration (p=0.01). Bootstrapping revealed minimal overfitting in both models. Conclusion:. A cluster of items identified NRI in LBLP consulters. These criteria could be used clinically and in research to improve accuracy of identification and homogeneity of this subgroup of low back pain patients

Aims

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES.

Purpose

To elucidate the efficacy of carrying out additional vertebral biopsy procedure during percutaneous balloon kyphoplasty as a tool in determining malignant etiology.

Introduction. Lumbosacral transitional vertebrae (LSTV) are increasingly recognized as a common anatomical variant and is the most common congenital anomaly of the lumbosacral spine. Patients can have symptomatic LSTV, known as Bertolotti's Syndrome, where transitional anatomy can cause back, L5 distribution leg, hip, and groin pain. We propose an outline for diagnosis and treatment of Bertolotti's Syndrome. Methods. We retrospectively reviewed over 500 patients presenting to the primary author with low back, buttock, hip, groin and/or leg pain from April 2009 through April 2024. Patients with radiographic findings of an LSTV and clinical presentation underwent diagnostic injections to confirm diagnosis of Bertolotti's syndrome. Treatment was determined based on patient's LSTV classification. 157 patients with confirmed Bertolotti's syndrome underwent surgical treatment. Results. Over 500 patients presented with an appropriate clinical presentation and radiographic findings of an LSTV. Diagnostic injections were targeted into the transitional anatomy confirming the LSTV as the primary pain generator to make the diagnosis of Bertolotti's syndrome. The decision in the type of surgical intervention, resection or fusion, was made based on patient's LSTV anatomy. 157 patients with confirmed Bertolotti's Syndrome underwent surgical treatment (121 fusions (77%), 36 resections (23%)). The classification system and surgical outcomes, in part, have been previously published in World Neurosurgery. Conclusion. We have outlined the best practice of diagnosis and treatment selection for Bertolotti's syndrome. We have shown significant improvement in outcomes based on this method. We hope to aid in both patient education and provide an outline on how clinicians can become knowledgeable on Bertolotti's syndrome. Conflicts of interest. No conflicts of interest. Sources of funding. No funding obtained

Aims. This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer. Methods. Adolescents suspected of AIS and scheduled for radiographs were included. Rasterstereographic scoliosis angle (SA), maximal vertebral surface rotation (ROT), and angle of trunk rotation (ATR) with a scoliometer were evaluated. The area under the curve (AUC) from receiver operating characteristic (ROC) plots were used to describe the discriminative ability of the SA, ROT, and ATR for scoliosis, defined as a Cobb angle > 10°. Test characteristics (sensitivity and specificity) were reported for the best threshold identified using the Youden method. AUC of SA, ATR, and ROT were compared using the bootstrap test for two correlated ROC curves method. Results. Of 212 patients studied, 146 (69%) had an AIS. The AUC was 0.74 for scoliosis angle (threshold 12.5°, sensitivity 75%, specificity 65%), 0.65 for maximal vertebral surface rotation (threshold 7.5°, sensitivity 63%, specificity 64%), and 0.82 for angle of trunk rotation (threshold 5.5°, sensitivity 65%, specificity 80%). The AUC of ROT was significantly lower than that of ATR (p < 0.001) and SA (p < 0.001). The AUCs of ATR and SA were not significantly different (p = 0.115). Conclusion. The rasterstereographic scoliosis angle has better diagnostic characteristics than the angle of trunk rotation evaluated with a scoliometer, with similar AUCs and a higher sensitivity. Cite this article: Bone Joint J 2023;105-B(4):431–438

Aims. To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory. Methods. Patients who underwent surgery for ASD, with a minimum of two-year follow-up, were retrospectively reviewed. In total, 210 patients were included and randomly allocated into training (70% of the sample size) and test (the remaining 30%) sets to develop the machine learning algorithm. Risk factors were included in the analysis, along with clinical characteristics and parameters acquired through diagnostic radiology. Results. Overall, 152 patients without and 58 with a history of surgical revision following surgery for ASD were observed; the mean age was 68.9 years (SD 8.7) and 66.9 years (SD 6.6), respectively. On implementing a random forest model, the classification of URO events resulted in a balanced accuracy of 86.8%. Among machine learning-extracted risk factors, URO, proximal junction failure (PJF), and postoperative distance from the posterosuperior corner of C7 and the vertical axis from the centroid of C2 (SVA) were significant upon Kaplan-Meier survival analysis. Conclusion. The major risk factors for URO following surgery for ASD, i.e. postoperative SVA and PJF, and their interactions were identified using a machine learning algorithm and game theory. Clinical benefits will depend on patient risk profiles. Cite this article: Bone Joint Res 2023;12(4):245–255

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

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Aims. The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD). Patients and Methods. Clinical features, radiology, results of microbiology, histology, and laboratory investigations in 50 suspected SD patients were evaluated. In 29 patients, the final (i.e. treatment-based) diagnosis was pyogenic SD; in seven patients, the final diagnosis was mycobacterial SD. In pyogenic SD, the neutrophil polymorph (NP) infiltrate was scored semi-quantitatively by determining the mean number of NPs per (×400) high-power field (HPF). Results. Of the 29 pyogenic SD patients, 17 had positive microbiology and 21 positive histology (i.e. one or more NPs per HPF on average). All non-SD patients showed less than one NP per HPF. The presence of one or more NPs per HPF had a diagnostic sensitivity of 72.4%, specificity 100%, accuracy 100%, positive predictive value (PPV) 81.0%, and negative predictive value (NPV) 61.9%. Sensitivity, specificity, and accuracy were greater using the criterion of positive histology and/or microbiology than positive histology or microbiology alone. Granulomas were identified histologically in seven mycobacterial SD patients, and positive microbiology was detected in four. Conclusion. The diagnosis of pyogenic SD was more often confirmed by positive histology (one or more NPs per HPF on average) than by microbiology, although diagnostic sensitivity was greater when both histology and microbiology were positive. Cite this article: Bone Joint J 2019;101-B:246–252

Aims. To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score. Methods. In this prognostic study, a multicentre, retrospective single-level vertebral augmentation cohort of 377 patients from six Japanese hospitals was used to derive an AVF prediction model. Backward stepwise selection (p < 0.05) was used to select preoperative clinical and imaging predictors for acute AVF after vertebral augmentation for up to one month, from 14 predictors. We assigned a score to each selected variable based on the regression coefficient and developed the AVA scoring system. We evaluated sensitivity and specificity for each cut-off, area under the curve (AUC), and calibration as diagnostic performance. Internal validation was conducted using bootstrapping to correct the optimism. Results. Of the 377 patients used for model derivation, 58 (15%) had an acute AVF postoperatively. The following preoperative measures on multivariable analysis were summarized in the five-point AVA score: intravertebral instability (≥ 5 mm), focal kyphosis (≥ 10°), duration of symptoms (≥ 30 days), intravertebral cleft, and previous history of vertebral fracture. Internal validation showed a mean optimism of 0.019 with a corrected AUC of 0.77. A cut-off of ≤ one point was chosen to classify a low risk of AVF, for which only four of 137 patients (3%) had AVF with 92.5% sensitivity and 45.6% specificity. A cut-off of ≥ four points was chosen to classify a high risk of AVF, for which 22 of 38 (58%) had AVF with 41.5% sensitivity and 94.5% specificity. Conclusion. In this study, the AVA score was found to be a simple preoperative method for the identification of patients at low and high risk of postoperative acute AVF. This model could be applied to individual patients and could aid in the decision-making before vertebral augmentation. Cite this article: Bone Joint J 2022;104-B(1):97–102

Introduction and Objective. Almost 60% of the population can expect to experience low back pain (LBP) during their life. Several radiological tools are used to investigate LBP. However, adequate evidence is unavailable to support the use of single photon emission computer tomography (SPECT) in patients with LBP. The objective of this study is to assess the role and efficiency of SPECT in evaluation and management of patients with LBP. Method. Ninety-two patients with LBP were examined and assessed. All the patients received a magnetic resonance imaging (MRI) scan and were referred for a SPECT. We interpreted the modic and degenerative changes found on the MRI and compared it with SPECT tracer uptake. SPECT was used to identify the pain generator and then a surgical plan was made. Data was analyzed for pain improvement in those who underwent surgical treatment to establish the accuracy of CT SPECT in identification of primary pain generator. Results. A total of 184 patients were included in the study who underwent diagnostic CT-SPECT between January 2013 and December 2019. One hundred of them were females and Eighty four males; the mean age was 47.6 years. 111 patients underwent surgery in the form of interbody fusion or posterolateral fusion. 16 patients positive tracer uptake was at asymptomatic level or unrelated. In 3 patients SPECT identified screw sites as pain generator and in all 3 patients screws were removed with good pain relief. Overall axial pain as measured with Numeric rating scale was preoperatively 9.13 ± 0.7 and improved to 4.54 ± 2.3 at 6 months postoperative follow up. MRI changes have been analyzed and correlation studied with relation to SPECT findings. Conclusion. Due to its high precision and sensitivity compared to other radiological modalities, SPECT demonstrated the ability to aid in clinical diagnosis. CT SPECT reveals information that becomes vital in deciding further management. In this study, we exemplified that SPECT scan can give indication for pain generator in axial spine pain and aid in surgical intervention