Purpose and Background

Physical mechanisms underlying back pain impairment are poorly understood. Measuring movement features linked to back pain should help understand its causes and decide on best management. Previous kinematic studies have pointed to diverse features distinguishing back pain sufferers. However, the complexity of 3D kinematics means that it is difficult to choose, a priori, which variables or variable combinations are most important. This study set out to obtain a rich set of kinematic data from spinal regions and lower extremities during typical movement tasks, and analyse all of these variables simultaneously to obtain globally important distinguishing features. To this end, a novel distance metric between pairs of motion sequences was used to construct distance matrices. Analyses were carried out directly on these distance matrices.

Purpose and background

Identifying features in nonspecific low back pain (NSLBP) subjects that distinguish them from controls, or for elucidating subgroups, has proved elusive. Yet these would be helpful to monitor progress, improve management, and understand the nature of the condition. Previous work using quantitative videofluoroscopy (QF) has indicated that the distribution of motion between lumbar intervertebral joints is more uneven in those with a history of NSLBP. However, there maybe other features of these complex motion patterns yet to be revealed. A multivariate analysis was therefore carried out to explore other possible differences.

Purpose

The importance of interpreting clinical trial results in terms of the benefits a treatment may offer to individuals with chronic pain is becoming more widely recognized. The clinical meaningfulness of group differences can better be described by looking at the percentages of responders in each treatment group, rather than between group mean differences. We have reassessed the outcomes of a clinical trial for chronic low back pain (LBP) from this new perspective.

Background. Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques. Methods. PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios. Results. Differences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented. Conclusion. The study is due to open in May 2024 and complete in 2026. Conflicts of Interest. No conflicts of interest declared. Sources of Funding. NIHR Health Technology Award – grant number NIHR153170. Trial presentations so far. APOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024

Background. Advice and education are considered vital components of back pain care within national guidelines. However, a recent systematic review only found low grade evidence for a small average effect. They also reported wide heterogeneity in intervention design and delivery. This review aimed to understand why intervention design varied and what limited effectiveness by examining the underlying theoretical foundations of the studies from that review. Method. Population, context, selection criteria, intervention(s), control, outcome measures, how the intervention was hypothesised to produce outcomes and author recommendations based on results of the study were extracted from text records. The extent to which the advice included matched a published international consensus statement on evidence-based advice for back pain was recorded. Whether interventions or settings were complex was determined using the Medical Research Council complex intervention development and evaluation guidance and the extent to which they met complexity reporting criteria was recorded. Results. The review included 26 trials conducted over 25 years. Differences In causal pathways could explain diversity in intervention design but these were not clearly described or evaluated. All studies were complex in terms of intervention and setting. This was rarely considered in intervention and trial design or when discussing the results. Although interventions were frequently described in detail only a few explained the process and justification of the design. Theories of education or behaviour change were rarely applied. Conclusion. These studies have not deepened our understanding of how education improves outcomes. Future RCTs should engage more with theory and other theory-based research methods should to be considered. Conflict of interest: No conflicts of interest. Sources of funding: No funding

Background. The advent of EOS imaging has offered clinicians the opportunity to image the whole skeleton in the anatomical standing position with a smaller radiation dose than standard spine roentgenograms. It is known as the fifth modality of imaging. Current NICE guidelines do not recommend EOS scans over x-rays citing: “The evidence indicated insufficient patient benefit in terms of radiation dose reduction and increased throughput to justify its cost”. Methods. We retrospectively reviewed 103 adult and 103 paediatric EOS scans of standing whole spines including shoulders and pelvis for those undergoing investigation for spinal deformity in a tertiary spinal centre in the UK. We matched this against a retrospective control group of 103 adults and 103 children who underwent traditional roentgenograms whole spine imaging at the same centre during the same timeframe. We aimed to compare the average radiation dose of AP and lateral images between the two modalities. We utilised a validated lifetime risk of cancer calculator (. www.xrayrisk.com. ) to estimate the additional mean risk per study. Results. In the Adult EOS Group (AEG) the mean estimated effective dose of AP was 0.08 mSv (0.04–0.15) and Lateral 0.06 mSv (0.03–0.14). Conversely in the Adult Roentgenograms Group (ARG) the mean AP was 0.49 mSv (0.15–1.88) and Lateral was 0.29 mSv (0.07–1.20). In the Paediatric EOS Group (PEG): the mean dose of AP was 0.07 mSv (0.02–0.21) and Lateral 0.04 mSv (0.02–0.11). Conversely Paediatric Roentgenograms Group (PRG) had a mean dose in AP of 0.37 mSv (0.03–5.92) and in lateral of 0.17 mSv (0.03–0.44). The percentage differences were: ARG:AES AP 613%, ARG:AES Lat 483%, PPG:PEG AP 529%, PRG:PEG Lat 425%. Mean difference 513%. The additional lifetime cancer risk for AEG was 1 in 176056 for males and 1 in 138696 for females, compared to ARG 1 in 31596 for males and 1 in 24894 for females. In PEG that was 1 in 58207 for boys and 1 in 33367 for girls, compared to PRG 1 in 11860 for boys and 1 in 6797 in girls. Differences in additional lifetime risk of cancer per scan: ARG:AES Male 557%, Female 557%, PRG:PEG Male 491%, Females 491%. Conclusion. Standard plain film imaging of the whole spine requires approximately five-times higher doses of radiation compared to dual planar EOS scans. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in both children and adults. There is approximately 5-fold increase in risk of cancer for all groups with roentgenograms over EOS. We directly challenge the NICE guidance and recommend EOS dual planar imaging in favour of plane roentgenograms for investigation of spinal deformity

Introduction. Patients with recurrent low back pain (LBP) exhibit changes in postural control. Stereotypical muscle activations resulting from external perturbations include anticipatory (APAs) and compensatory (CPAs) postural adjustments. This study aimed to determine differences in postural control strategies (APAs and CPAs) between those with and without lumbar disc degeneration (LDD) and LBP. Methods. Ninety-seven subjects participated in the study (mean age 50 years (SD 12)). 3T MRI was used to acquire T2 weighted images (L1-S1). LDD was determined using Pfirrmann grading and LBP using the numerical rating scale (NRS). A bespoke perturbation platform was designed to deliver postural perturbations. Electrical activity was analysed from 16 trunk and lower limb muscles during four typical APA and CPA epochs. A Kruskal-Wallis H test with Bonferroni correction for multiple comparisons was conducted. Results. Four groups were identified; ‘no LDD no pain’ (n = 19), ‘LDD no pain’ (n =38), ‘LDD pain’ (n =35) and ‘no LDD pain’ (n = 5). There was no significant difference in age or gender between groups. Although, increased BMI was associated with LBP it did not correlate with significant findings. Significant differences in APAs and CPAs were observed between ‘LDD pain’ and ‘LDD no pain’ groups during predicted and unpredicted perturbations (p=0.009–0.049, r=0.31–0.43). Significant CPAs correlated with LBP (p=0.001–0.03) but did not correlate with LDD (p=0.22–0.94). Conclusion. Postural control strategies are different between those with LDD and pain and those without. Differences in compensatory strategy are associated with the presence of pain and not LDD. No conflicts of interest. Sources of Funding: Janet Deane is funded by an Allied Health Professional Doctoral Fellowship awarded by Arthritis Research U.K. (ARUK)

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

Aims

Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre.

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

Aims

The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

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.

Aims

The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment.

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction?

Background and Purpose of Study:. Differences in regional lumbar angles in sitting have been observed between subgroups of NSCLBP patients exhibiting motor control impairments (MCI) (O'Sullivan, 2005; Dankaerts et al, 2006). However, differences in standing posture and other spinal regions are unknown. This study aimed to compare regional spinal angles in healthy and MCI subgroups in sitting and standing. Methods:. An observational, cross-sectional study investigated spinal kinematics of 28 Flexion Pattern (FP), 23 Active Extension Pattern (AEP) (O'Sullivan, 2005) and 28 healthy controls using 3D motion analysis (Vicon) during usual sitting and standing. Mean sagittal angle for Total Lumbar (TotLx), Total Thoracic (TotTx), Upper Thoracic (UTx), Lower Thoracic (LTx), Upper Lumbar (ULx) and Lower Lumbar (LLx) regions between groups were compared using one-way ANOVA. Results:. No differences in total thoracic and lumbar regions were observed, except TotLx in sitting between FP and AEP (Mean Difference (MD)=15.81°, p=0.003). Significant differences were observed in ULx and LTx for standing and sitting between FP and AEP (ULx Standing MD=9.89°, p=0.003; ULx Sitting MD=12.32°, p=0.000; LTx Standing MD=7.57°, p=0.05; LTx Sitting MD=11.72°, p=0.001) with AEP demonstrating greater extension in these regions. FP exhibited greater flexion compared to controls in ULx and LTx, except LTx in standing (ULx Standing MD=7.69°, p=0.018; ULx Sitting MD=6.96°, p=0.014; LTx Sitting MD=11.28°, p=0.001). No differences between AEP and controls were observed in sitting or standing. Conclusion:. Observing subdivided regional spinal angles is key to identifying MCI sub-group differences, with ULx and LTx able to discriminate between FP and AEP, and FP and healthy controls. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: Arthritis Research UK / Presidents Research Scholarship, Cardiff University

Lumbar myelography was a commonly performed procedure but was superseded by MRI and CT which were low risk and provided cross-sectional information. The majority of MRI and CT evaluations are static and supine whereas myelography may be loaded and dynamic. This study evaluates the role of myelography in patients with degenerative scoliosis in a modern surgical practice. Patients with degenerative scoliosis and full imaging (plain radiographs, supine MRI, myelography, including CT myelography) were identified from our database between 2006-2009. Differences between findings of MRI and myelography/CT myelography were noted and whether this subsequently affected treatment. 21 patients fulfilled inclusion criteria. Mean age 68 (45-82), 17 females. 18/21(85.7%) myelograms revealed findings not seen on MRI. 15 patients had a single abnormality, 1 had two and in 2 patients there were 3 new abnormalities. These were facet/ligamentous bulging in 13, a single spondylolisthesis, retrolisthesis and lateral subluxation. On CT a foraminal osteophyte and a pars defect were seen. In 4 cases supine investigation revealed more than MRI. In 7 patients management changed as a result of myelography/CT. There have been no complications of myelography in our unit of the total 270 performed. Myelography is a safe and useful tool in the management of patients with degenerative scoliosis. MRI scan alone understates the true nature of central and lateral recess stenosis. Not only does myelography show more stenosis in the loaded spine, but static myelography and CT myelography are also an invaluable tool in these patients

Purpose and background. Although low back pain (LBP) with leg pain, is considered by most a poor prognostic indicator, it is at the same time believed to have a favourable natural resolution, and is often treated along similar lines to non-specific LBP, in line with current guidelines. It is unclear whether patients with LBP and leg pain are a distinct subgroup that might benefit from early identification and targeted interventions. We set out to investigate the impact of LBP with leg pain on health outcomes and health resources compared with that of LBP alone, and to explore which factors contribute to the observed disability outcomes. Methods. A systematic literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1994 to 2009. Results. Of the 89 papers retrieved, 9 were included in the review. The heterogeneity of data allowed only for narrative analysis of findings. All studies reported worsening baseline health status in terms of poorer self-assessment and increasing use of health care the further the radiation of leg pain. Differences in quality of life measures were higher for physical than for mental health dimensions. Pain and disability outcome at follow up assessment appeared to be less favourable in this group than for individuals with LBP alone. Conclusion. LBP with leg pain is associated with poorer health outcomes and increased use of health resources. These findings argue for early identification of these cases by health care professionals and for pursuing effective treatments rather than simply treating similarly to non-specific LBP

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice

Aims

The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC).