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

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

Background. There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care. Purpose. To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP). Methods. LBLP patients in a primary-care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible NP) at baseline and 4-months. Mixed effects models compared pain-intensity (highest of mean leg or mean back pain - 0–10 NRS at baseline, 4-months, 12-months and 3-years) between those with persistent NP (s-LANSS ≥12 at baseline and 4-months) and those without (s-LANSS ≥12 at baseline and <12 at 4-months). Univariable and multivariable binary logistic regression examined association between potential prognostic factors (chosen from baseline self-report questionnaires, clinical examination, MRI scan findings) and persistent NP. Multiple imputation was used to account for missing data. Results. 44% (72/164) of patients with NP at baseline had persistent NP at 4-months. Mean pain intensity of patients with persistent NP was higher at 4-months, 12-months and 3-years compared to those without. In univariable analysis, only pain self-efficacy was significantly associated with persistent NP (OR 0.98, 95% CI 0.96 to 0.998). In multivariable analysis, none of the 7 investigated factors were significantly associated with persistent NP. Conclusion. Patients with persistent NP were consistently worse-off up to 3-years follow-up compared to those without. It was difficult to identify those patients with NP at baseline who would have persistent NP at 4-months. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship for Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Purpose of study and background. This study aimed to investigate if the PD-Q classification was predictive of outcomes at 3 and 12-months follow-up in LBP patients with associated leg pain. Identification of clinically important subgroups and targeted treatment is believed to be important in low back pain (LBP) care. The PainDETECT Questionnaire (PD-Q) is designed to classify whether a person has neuropathic pain, based on their self-reported pain characteristics. However, it is unknown whether this classification is a prognostic factor and/or predicts treatment response. Method and results. 145 participants were recruited in secondary care. Inclusion criteria were 3-12 months LBP and leg pain. Baseline PD-Q scores classified participants into three groups (likely to have neuropathic pain, uncertain, unlikely) but did not affect treatment decisions. The outcome measures were LBP, leg pain, activity limitation and self-reported general health. Scores were compared between those with ‘likely’ neuropathic pain (neuropathic group) and ‘unlikely’ (non-neuropathic group), using Mann-Whitney, Friedman and Chi Square tests. At baseline, the neuropathic group had worse scores on all outcome measures, and analgesic use, sick leave, sense of coherence and psychological profile (p=.000 to .044). At 3-months and 12-months both groups improved (p=.001 to .032). However, the groups remained different at each time point on all outcome measures (p=.000 to .033) except LBP (p=.054 to .214). Conclusions. The PD-Q classification was a prognostic factor but was not predictive of response to generic care. Further studies should investigate whether PD-Q groups are predictive of response to neuropathic pain targeted treatment

Purpose of the study. The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision. Methods. This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging. Results. Thirty-three participants were recruited and a total of 45 interviews being carried out. 7 central themes and 17 sub-themes were generated from thematic analysis. The first-line treatment administered to all participants by their G.P was a combination of analgesia. The drugs used included paracetamol, ibuprofen, nefopam, diclofenac, tramadol, morphine, diazepam and baclofen. Neuropathic pain modulating medication such as amitriptyline, gabapentin or pregabalin was widely used. Participants reported that medication simply didn't provide sufficient pain relief at a dose where side-effects were acceptable. Twenty-four interviewees described the negative side-effects of the drugs including nausea, dizziness, confusion, constipation, drowsiness, impotence and bloating. Furthermore, participants were concerned about their ability to carry out normal day to day tasks such as childcare, work and driving due to the side-effects of the drugs. Conclusion. Sciatica can be all encompassing, with severe pain and disability. A range of medication is commonly used for pain relief. The results from this study suggest that the drugs don't provide significant pain relief without deleterious side-effects in some patients. No conflicts of interest for any authors. Sources of funding: MR is the recipient of a HEE/NIHR Clinical Doctoral Research Fellowship which funded the study

Background. Medication prescribing patterns for patients with neuropathic low back-related leg pain (LBLP) in primary care are unknown. Purpose. To estimate the proportion of patients prescribed pain medications, describe baseline characteristics of patients prescribed neuropathic pain (NP) medication and estimate the proportion of LBLP patients with refractory NP. Methods. General practice electronic medical and prescribing records of a large (n=609), prospective, primary-care cohort of LBLP patients were analysed. Cases of NP were identified using the self-report version of the NP scale, Leeds Assessment for Neurological Symptoms and Signs (score of ≥12 indicates possible NP) (n=293). Patients with leg pain intensity ≥ 5 (mean of three 0–10 NRSs) or <30% reduction in disability (RMDQ 0–23) at 4-months compared to baseline and who were prescribed ≥ 2 NP medications were considered to have refractory NP. Results. 82% (223/273) of patients with NP were prescribed at least one pain medication; 29% (80/273) of patients were prescribed one first-line NP medication (for example Amitriptyline). Patients who were prescribed NP medication(s) had higher leg pain intensity and disability. There was evidence that patients improved with (61%, 41/67) and without (75%, 76/102) having been prescribed NP medication. Few patients (4%, 7/169) met the criteria for refractory NP suggesting that the scale of the problem in primary care is limited. Conclusion. Patients with NP were commonly prescribed pain medication, under a third were prescribed NP medication and many patients improved without such medication. Future research is needed to determine the effectiveness of NP medication. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship awarded to Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Background. 60% of back pain patients report pain radiation in the leg(s), which is associated with worse symptoms and poorer recovery. The majority are treated in primary care, but detailed information about them is scarce. The objective of this study is to describe the characteristics of patients with back and leg pain-seeking treatment in primary care. Methods. Adult patients consulting their GP with back and leg pain were invited to the study. Participants completed questionnaires including sociodemographic, physical and psychosocial measures. They also underwent standardised clinical assessments by physiotherapists, and received an MRI scan. Results. 609 patients participated with 67.5% reporting pain below the knee. 62.6% were female, sample mean (SD) age 50.2 (13.9). 367 (60.7%) were in paid employment with 39.7% reporting time off work. Mean disability (RMDQ) was 12.7 (5.7) and mean pain intensity was 5.6 (2.2) and 5.2 (2.4) for back and leg respectively. Mean sciatica bothersomeness index (SBI) score was 14.9 (5.1). 74.2% (452/609) were clinically diagnosed as having sciatica. Patients in the sciatica group reported significantly higher levels of leg pain and SBI scores, leg pain worse than back pain and pain below the knee. Neuropathic pain was more prevalent in patients with referred leg pain. Conclusion. This primary care cohort reported high levels of disability and pain. Three quarters were diagnosed with sciatica. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics. This abstract summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0707-10131). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. 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. K. Konstantinou is supported by a HEFCE/NIHR Senior Clinical Lectureship. KM Dunn is supported by the Wellcome Trust (083572)

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Establish the prevalence of B12 deficiency in patients presenting for surgical assessment and to audit subsequent management. Retrospective: The pathology database was interrogated for all B12 and folate requests under the name of a Spine sub-specialty Consultant over a four year period (2005-2008). 38 patients with B12 deficiency were identified. Patient self reported symptoms, drug history, Global outcome score (Much better, better, same, worse) Visual Analogue Score (VAS) and Oswestry Disability Index(ODI). 458 tests occurred. 38(8.3%) were B12 deficient. Of these, 10 (26%) had received no treatment at review. Average age 63 years. 23 males, 15 females. 6 patients were diabetic. At clinic attendance Mean ODI 46%; VAS(leg) 6.4. A sample from those with a normal B12 had ODI 45%; VAS(leg) of 5.9. Of the three who were “worse”, one had been treated. 7 of the 12 patients who felt the “same” had received injections. 9 were “better” with 5 on supplements. Five were “much better” with all patients on supplements. Less than half(47%) were prescribed analgesia, 11 out of 38 were taking paracetamol, 6 were prescribed NSAIDs, 6 opiates, and 10 were taking neuropathic painkillers. Reversible causes of neuropathic pain can only be identified by testing. A high index of suspicion resulted in positive tests in 8% of the population studied. Administrative obstacles exist to treatment. Those that are treated do better. Sensory symptoms in a spine clinic patient should not be assumed to originate exclusively from the spine. Audit/service standard registered in Trust No conflict of interest

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

Non-coding microRNA (miRNA) in extracellular vesicles (EVs) derived from mesenchymal stem cells (MSCs) may promote neuronal repair after spinal cord injury (SCI). In this paper we report on the effects of MSC-EV-microRNA-381 (miR-381) in a rodent model of SCI.

Objectives

In order to elucidate the influence of sympathetic nerves on lumbar radiculopathy, we investigated whether sympathectomy attenuated pain behaviour and altered the electrical properties of the dorsal root ganglion (DRG) neurons in a rat model of lumbar root constriction.

Aims

The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life.

The aim of this study was to evaluate the feasibility of using the intact S1 nerve root as a donor nerve to repair an avulsion of the contralateral lumbosacral plexus. Two cohorts of patients were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients with a unilateral fracture of the sacrum and sacral nerve injury were stimulated during surgery to establish the precise functional distribution of the S1 nerve root and its proportional contribution to individual muscles. In cohort 2, the contralateral uninjured S1 nerve root of six patients with a unilateral lumbosacral plexus avulsion was transected extradurally and used with a 25 cm segment of the common peroneal nerve from the injured leg to reconstruct the avulsed plexus.

The results from cohort 1 showed that the innervation of S1 in each muscle can be compensated for by L4, L5, S2 and S3. Numbness in the toes and a reduction in strength were found after surgery in cohort 2, but these symptoms gradually disappeared and strength recovered. The results of electrophysiological studies of the donor limb were generally normal.

Severing the S1 nerve root does not appear to damage the healthy limb as far as clinical assessment and electrophysiological testing can determine. Consequently, the S1 nerve can be considered to be a suitable donor nerve for reconstruction of an avulsed contralateral lumbosacral plexus.

Cite this article: Bone Joint J 2015; 97-B:358–65.

We describe three patients with pre-ganglionic (avulsion) injuries of the brachial plexus which caused a partial Brown-Séquard syndrome.

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.