Aim. NICE guidance on lumbar total disc replacement (TDR) recommends ongoing audit should be an integral part of disc replacement surgery. We present our ongoing audit data and the extent of problem of patients lost to follow up. Method. 35 patients underwent lumbar TDR surgery over 4.5 years. They were followed prospectively. A database is maintained and ODI and VAS were collected prospectively, including patient satisfaction and any failures. Results. At latest follow up full data was available for 30 out of 35 patients. The mean follow-up was 34 months (range 3-52 months). There were 13 males with a mean age 37.7 years (range 27-62) and 17 females with a mean age of 49.8 years (range 27-62). Surgery was single level in 24 cases and double level in 6 cases. 21 patients rated their outcome as good or very good and 7 as unsatisfactory. There were 2 failures, one secondary to late extrusion of the polyethylene liner (12 months post-surgery) and one early anterior migration of the prosthesis. ODI scores improved by a mean of 28 points (range -4 to 68) whilst VAB scores improved by a mean of 4.9 (range -1 to 9). Five patients had been lost to follow up. One patient migrated out of the area. Two came from out of the area and did not return for follow up after the initial period and two further patients DNAed multiple clinic appointments. Conclusion. We conclude that lumbar disc replacement surgery can provide substantial improvement in pain relief and function. Continued audit of this cohort of patients is essential to comply with NICE guidance. 14% loss to follow up/audit is encountered despite our best effort

Introduction. Adolescent idiopathic scoliosis (AIS) is the most common paediatric spinal deformity, affecting about 3% of school-aged children worldwide. This disorder occurs in otherwise healthy children who bear no obvious deficiencies in the components of the spinal column itself. The cause of AIS is poorly understood, as is implied by the name. Lesions of the bony composition of the vertebrae, the vertebral endplates, the paraspinous muscles, or the neurological system each have been proposed to explain disease pathogenesis. Progress has been hampered by the absence of an obvious AIS animal model. Consequently we have used genetic studies in human populations to identify factors underlying AIS susceptibility. The complex inheritance and population frequency of AIS suggest that many genetic factors are involved in this disease. To search comprehensively for such factors we previously undertook the first genome-wide association study (GWAS) of AIS susceptibility in a cohort of 419 families in Texas, USA. We found that chromosome 3 SNPs in the proximity of the CHL1 gene yielded strongest results, which we replicated in additional cohorts (rs10510181 OR 1·49, 95% CI 1·29–173, p=2·58×10–8). CHL1 is of interest because it encodes an axon guidance protein and is functionally related to the ROBO3 gene that causes hereditary gaze palsy with progressive scoliosis (HGPPS), a rare disease marked by severe scoliosis. Here we expanded the study to 702 Texas families. Methods. We tested more than 327 000 single-nucleotide polymorphisms (SNPs) across all human autosomes for association with disease. Results. Results of the study in 702 Texas families yielded evidence for association with SNPs in a second axon guidance gene, DSCAM, which encodes a protein in the same structural and functional class with Chl1 and Robo3 (rs2222973 combined OR 0·59, 95% CI 0·48–0·74; p=1·46×10–6). We additionally found AIS associations with loci in CNTNAP2, whose protein product interacts directly with L1 and Robo class proteins and participates in axon pathfinding. Conclusions. These data support genetic variation in axon guidance genes as risk factors in AIS. Our results provide new insight into disease pathogenesis and suggest that late-onset scoliosis may be correlated with secondary neurological development

Computer-assisted frameless stereotactic image guidance allows precise preoperative planning and intraoperative localisation of the image. It has been developed and tested in the laboratory. We evaluated the efficacy, clinical results and complications of placement of a pedicle screw in the lumbar spine using this technique. A total of 62 patients (28 men, 34 women) had lumbar decompression and spinal fusion with segmental pedicle screws. Postoperative CT scans were taken of 35 patients to investigate the placement of 330 screws. None showed penetration of the medial or inferior wall of a pedicle. Registration was carried out 66 times. The number of fiducial points used on each registration averaged 5.8 (4 to 7) The mean registration error was 0.75 mm (0.32 to 1.72). This technique provides a safe and reliable guide for placement of transpedicular screws in the lumbar spine

Background and study purpose. Low back pain with no identified underlying cause is categorised as primary musculoskeletal pain by the International Association for the Study of Pain. In April 2021, the National Institute for Care and Excellence (NICE) published updated guidance for the management of primary chronic pain conditions in England. As part of the De-STRESS pain study, we explored the perspectives of GPs on the updated guideline and impact upon clinical practice. Methods and results. Semi-structured interviews were conducted with 21 GPs in England. Data were analysed using thematic analysis and constant comparison techniques. GPs agreed with the recommendations restricting pharmacological options for pain management and reflected that they now had an expert reference to back-up their decision-making and could use the guidance in potentially difficult conversations with patients. Frustration was expressed by GPs about the lack of alternative options to medication, as the non-pharmacological recommendations were difficult to implement, had lengthy waiting lists, or were unavailable in their locality. Conclusion. Although GPs discussed benefits of the updated NICE guideline in potentially reducing prescriptions of ineffective and potentially harmful medications, frustration about the lack of alternative strategies added to the difficulties encountered in managing people with persistent back pain in primary care. Conflicts of interest: No conflicts of interest. 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

Background. Chronic pain is a significant burden and represents a major issue for world healthcare systems. Interventions include medication, surgery, pain management programmes, and social support through peer support groups. These groups are often informal, providing informational, emotional, and social support to members. The aim of this project is to co-produce guidance on how to establish a peer support programme for people living with chronic, non-cancer pain that is informed by evidence, theory, and stakeholder experience. Methods. This project is using Steps 1–4 of the Intervention Mapping (IM) approach to inform the research. Online workshops consisting of people living with chronic pain, third sector representatives, healthcare professionals, and researchers are being used to co-produce the guidance. Results. To date, 2 of the 4 planned workshops have been conducted. These have identified the needs of people living with chronic pain, goals for the peer support programme, and expectations of how a peer support programme should be executed. Topics for inclusion in the programme and their content have been identified, with further workshops to refine this planned. The final stage of this project will identify methods of delivery, specific resources that should be developed, and the training to be provided to peer support volunteers. Conclusion. The project has identified the diverse needs of people living with chronic pain and how these may be addressed by a peer support programme. It has identified flexible options that can be recommended to those who want to set up a programme and a variety content that may be included. Conflicts of Interest. None. Sources of Funding. Robert Gordon University

Background. Specifically designed control interventions can account for expectation effects in clinical trials. For the interpretation of efficacy trials of physical, psychological, and self-management interventions for people living with pain, the design, conduct, and reporting of control interventions is crucial. Objectives. To establish a quality standard in the field, core recommendations are presented alongside additional considerations and a reporting checklist for control interventions. Methods. Three Delphi rounds with 64 experts in placebo research and/or non-pharmacological clinical trials were conducted. The panel was presented with a systematic review and meta-analysis of control and blinding methods. A draft guidance document included 63 consensus items (≥80% agreement) and was discussed with patient partners. Finally, the draft guidance and results from stakeholder interviews were discussed at consensus meetings with Delphi participants and patient representatives. Results. Forty-four experts completed the process. When treatment efficacy or mechanisms are to be studied, the advocated principle is to design control interventions as similar as possible to the tested intervention, apart from the components that the study examines. Structured reasoning in the planning phase, early engagement with stakeholders, feasibility work, and piloting will enhance the quality and acceptability of control interventions. With participant blinding being a primary objective, blinding effectiveness should be routinely assessed and reported. Transparent and detailed reporting will improve interpretability and repeatability of clinical trials. Conclusion. This guideline provides the much-needed standards to enhance the quality of efficacy clinical trials in physical, psychological, and self-management intervention research, ultimately improving patient care. Study registration: . https://osf.io/jmyhq/. Conflict of interest: The authors declare no competing interests. Sources of Funding: Alain and Sheila Diamond Charitable Trust PhD Studentship

Purpose and background. Low back pain burdens individuals, society and services, including Emergency Departments (ED), straining services and prolonging wait times. Despite reported personal influences on deciding to attend ED, the role of third-party advice remains underexplored. Sparse guidance for clinicians and service-users highlights the need for effective back pain management strategies, to alleviate system pressure and optimise patient outcomes. This study explored how advice influences the decision to attend the ED for back pain. Methods and Results. From a subtle realist stance, the design was a secondary analysis of qualitative data, where 47 patients (26M:21F, aged 23–79 years) with back pain were purposively sampled from four EDs (2 Northern and 2 Southern) in England between August and December 2021. Eight patients had previously visited ED for this episode of back pain. As this was during the pandemic, semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed using a reflective thematic analysis. Three themes were identified as crucial in making the decision to attend ED: The Healthcare professional; Trusted others; and the Individual. Healthcare professionals often dictated decisions, leaving participants feeling powerless. Trusted others provided varying support levels, often acting as allies. Individuals grappled with anxieties around their condition and treatment expectations. Conclusion. This study highlights the need for clinicians to provide clarity and guidance to individuals and their Trusted others, seeking advice regarding escalation to visit the ED with back pain. There was evidence that worrying about pain was a significant motivator for attending ED, resulting in malalignment with current practice guidelines. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

We present a large single surgeon case series evaluation of a new growth guidance technique for the treatment of progressive early onset scoliosis (EOS). A traditional Luque trolley construct uses wires to hold growth guidance rods together. We describe a new technique that uses domino end to side connectors in place of the wires with the aim of providing a stronger construct to better limit curve progression, while allowing longitudinal growth. We did a thorough retrospective review of patient records and radiological imaging. Sequential measurements of Cobb angle and length of rods were recorded, as well as any further surgical procedures and associated complications. This enabled us to quantify the ability of a technique to limit curve progression and simultaneously allow growth of the construct. In total, 28 patients with EOS (20 idiopathic, four syndromic, and four neuromuscular) have been treated with this technique, 25 of whom have a minimum follow-up of 2 years and 13 have a minimum follow-up of 5 years. The average correction of the preoperative Cobb angle was 48.9%. At the 2-year follow up, the average loss of this initial correction was 15 degrees, rising to only 20 degrees at a minimum of 5 years (including four patients with a follow-up of 8 years or more). The growth of the constructs was limited. The average growth at 2 years was 3.7 mm, rising to 19 mm at the 5-year follow-up. Patients who underwent surgery with this technique before the age of 8 years seemed to do better. This group had a revision rate of only 18% at an average time of 7 years after the index procedure, and the average growth was 22 mm. However, the group that had index surgery after the age of 8 years had a 64% revision rate at an average of 3.2 years after surgery and an average growth of only 11.6 mm. Overall, in the cases series, there were four hardware failures (14%) and one deep infection (3.5%), and only ten patients (36%) had one extra surgery after the index procedure. Only two of the 13 patients who are at a follow-up of 5 years or more have had revision. This modified Luque trolley technique has a good capacity for initial curve correction and for limiting further curve progression, with limited longitudinal growth before 2 years and improved growth thereafter. This technique might not be so useful after the age of 8 years because of poor growth and a higher early revision rate. We have also demonstrated a low cost technique with a low hardware failure rate that saves many future surgeries for the patient compared with other techniques used in the treatment of EOS

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. 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

Purpose and background. Although clinical guidelines recommend that low back pain (LBP) is best managed in primary or community care, in the UK and globally, LBP accounts for around 4% of emergency department (ED) attendances. Organising and delivering healthcare to be safe, effective, and acceptable requires hearing patients’ perspectives; this study therefore aimed to explore patients’ experiences of attending the ED for LBP. Methods and results. This was a multisite qualitative interview study with 47 adults (aged 23–79 years) who, in the past six weeks, had attended one of four UK NHS emergency departments for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting site, and LBP and demographic characteristics. Data were collected using individual, semi-structured, telephone interviews (median 45mins). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. We identified significant variation in patients’ experiences of ED care for LBP, which we argue reflects contrasting cultures of ED care. We present three cultures, emergency screening only, ‘cynicism and neglect’, and ‘kindness’; these cultures differ in how they navigate the tension between the ED remit and patients’ perceived needs of care. We draw on Bourdieu's notions of field and habitus and professional identity theory to help explain these findings. Conclusion. Our findings suggest unwarranted variation in ED care for LBP. Implications include the need for urgent access to primary and community care and clarity about best practice managing LBP in the ED; best practice guidance and strategies to implement this should be informed by notions of culture and professional identity. No conflicts of interest.  . Sources of funding. Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

Purpose and Background. Work-related musculoskeletal disorders (WRMSD) can affect 56–80% of physiotherapists. Patient handling is reported as a significant risk factor for developing WRMSD with the back most frequently injured. Physiotherapists perform therapeutic handling to manually assist and facilitate patients’ movement to aid rehabilitation, which can increase physiotherapists risk of experiencing high forces during patient handling. Methods and Results. A descriptive cross-sectional study was completed to explore and quantitatively measure the movement of ten physiotherapists during patient handling, over one working day, in a neurological setting. A wearable 3-dimensional motion analysis system, Xsens (Movella, Henderson, NV), was used to measure physiotherapist movement and postures in the ward setting during patient treatment sessions. The resulting joint angles were reported descriptively and compared against a frequently used ergonomic assessment tool, the Rapid Upper Limb Assessment (RULA). Physiotherapists adopted four main positions during patient handling tasks: 1) kneeling; 2) half-kneeling; 3) standing; and 4) sitting. Eight patient handling tasks were identified and described: 1) Lie-to-sit; 2) sit-to-lie; 3) sit-to-stand; facilitation of 4) upper limb; 5) lower limb; 6) trunk; and 7) standing treatments; and 8) walking facilitation. Kneeling and sitting positions demonstrated greater neck extension and greater lumbosacral flexion during treatments which scores highly with the RULA. Conclusion. This research identified that patient treatment tasks were more often performed in kneeling or sitting positions than standing. Current moving and handling guidance teaches moving and handling in a standing position; loading and stresses experienced by the physiotherapists may differ in sitting or kneeling positions. Conflicts of interest. None. Sources of funding. None. This work has been presented as a poster at the CSP conference Glasgow 2023

Thoracolumbar injury classification systems are not used or researched extensively in paediatric population yet. This systematic review aims to explore the validity and reliability of the two main thoracolumbar injury classification systems in the paediatric population (age ≤ 18). It also aims to explore the transferability of adult classification systems to paediatrics. The Thoracolumbar Injury Classification System (TLICS) published in 2005 and the AO Spine published in 2013 were assessed in this paper because they both provide guidance for the assessment of the severity of an injury and recommend management strategies. A literature search was conducted on the following databases: Medline, EMBASE, Ovid during the period November 2020 to December 2020 for studies looking at the reliability and validity of the TLICS and AO Spine classification systems in paediatric population. Data on validity (to what extent TLICS/ AO Spine recommended treatment matched the actual treatment) and reliability (inter-rater and intra-rater reliability) was extracted. There is an “almost perfect validity” for TLICS. There is a “strong association” between the validity of TLICS and AO Spine. The intra-rater reliability is “moderate” for TLICS and “substantial” for AO Spine. The intra-rater reliability is “substantial” for TLICS and “almost perfect” for AO Spine. The six studies show a good overall validity and reliability for the application of TLICS and AO Spine in pediatric thoracolumbar fractures. However, implication of treatment and anatomical differences of the growing spine should be explored in detail. Therefore, AO Spine can be used in absence of any other classification system for paediatrics

Background and purpose of the study. Axial Spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5- 8 years with impacts on effective and timely management, outcomes and quality of life. NICE Guidance (2017) highlights the importance of the recognition and referral of suspected axial spondyloarthritis. This study investigated the occurrence of physiotherapy care prior to diagnosis of axSpA within physiotherapy outpatient settings. Methods and results. A retrospective review was performed of all patients diagnosed with axSpA who had received physiotherapy care prior to their diagnosis from 1990–2016. Three or more episodes of care prior to diagnosis was taken as unrecognised axSpA. Information was obtained on diagnostic codes, number of episodes of care and contacts per episode from nine outpatient physiotherapy services. Analysis showed that 263 people (17–69 years) diagnosed with axSpAs had received physiotherapy care prior to diagnosis. Within this population, 103 (44%) had received ≥3 episodes of care. Number of contacts within each episode ranged from 3 (47 people) to 58 (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy episode to date of diagnosis was 6.4 years (range=0.3–12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Conclusion. Findings illustrate the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal physiotherapy practice. It is essential to improve screening and recognition of inflammatory back pain and possible axSpA in musculoskeletal assessments, supported by rheumatology referral guidance. No conflicts of interest. No funding obtained

Introduction. The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires. Materials and Methods. Whilst positioned in the supine or lateral position, a routine supine anterior lumbar interbody fusion (ALIF), and/or antero-lateral ALIF (AL-ALIF) and/or lateral lateral interbody fusion (LLIF) is performed. The patient is then turned prone or kept in the single lateral position (SPL) for insertion of the posterior screws performed under robotic guidance. Intraoperative CT scan 3D images captured then are sent to the Robotic software platform for planning of the screw trajectories and finally use again at the end of the procedure to confirm screw accuracy. We identified 34 consecutive patients from October 2019 to January 2020 who underwent robotic assisted spine surgery. The demographic, intraoperative, and perioperative data of all these patients were reviewed and presented. Results. Of the 34 patients, 65 levels were treated in total using 204 screws. Of the 21 patients (60%) who underwent single-level fixation, 14 of them (67%) were treated at the L5/S1 level, 3 at L3/L4, 3 at L4/L5 and 1 at L2/L3 level. The remaining 13 patients (40%) underwent multi-level fixation, of which 4 were adult scoliosis. 15 underwent a supine ALIF approach, 1 underwent AL-ALIF, 8 patients underwent combined LLIF and AL-ALIF approach in a lateral decubitus, whilst 9 underwent pure LLIF approach (of which 3 patients were in the single position lateral) and one patient had previous TLIF surgery. The average estimated blood loss was 60 cc. The average planning time was 10 min and the average duration of surgery was 50 min. The average patient age was 54 years and 64% (22/34) were male. The average BMI was 28.1 kg/m. 2. There were no re-interventions due to complications or mal positioned screws. Conclusion. Minimally invasive spine surgery using robot-assisted navigation yields an improved level of accuracy, decreased radiation exposure, minimal muscle disruption, decreased blood loss, shorter operating theatre time, length of stay, and lower complication rates. Further follow-up of the patients treated will help compare the clinical outcomes with other techniques

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

Background. Work disability due to low back pain (LBP) is a global concern, resulting in significant healthcare costs and welfare payments. In recognition of this, recent UK policy calls for healthcare to become more ‘work-focused’. However, an ‘evidence-policy’ gap has been identified, resulting in uncertainty about how this is to be achieved. Clear, evidence-based recommendations relevant to both policy-makers and healthcare practitioners are required. Methods. A policy theory approach combining scientific evidence with governance principles in a pragmatic manner was undertaken. This entailed extracting evidence from a recent review of the system influences on work disability due to LBP* (focused specifically on the healthcare system) and appraising it alongside the most recent review evidence on the implementation of clinical guidance, and policy material aimed at developing work-focused healthcare. Results. It was found that further resources are needed to assist healthcare professionals (HCPs) to engage in work discussions with LBP patients, which can often be complex and challenging. HCPs themselves often have misconceptions about the work-health relationship and the related evidence-based guidance. System-level barriers that reduce access to suitable healthcare at the right time, and those that increase conflict with other key stakeholders (e.g. the workplace and welfare/compensatory systems) were found to be significant obstacles. Supportive policy and legislation that (a) embeds work as a health outcome, and (b) enables all key stakeholders to collaborate would be a major vehicle to facilitate work-focused healthcare for LBP. Conclusions. Accepting that work-focused healthcare for LBP is required does not diminish the challenge it presents. Evidence-based recommendations relevant for both policy and practice would enable a better understanding of what works for whom, and at what cost. *A full description and results of the evidence synthesis were presented at the Society's Annual Meeting 2016 and will be presented at the 15th International Forum for Back and Neck Pain Research in Primary Care 2017. These results also form part of a chapter in ISSLS Online Textbook 2017. Conflicts of interest; None. Sources of funding: None

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained