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

Background. Current policy and practice aimed at tackling work disability due to low back pain is largely aligned with the Psychosocial Flags Framework, which focuses on addressing individual beliefs and behaviours (yellow and blue flags). However, our understanding of the systemic and contextual factors (black flags) that are also proposed to act as obstacles within this Framework is under-represented, resulting in a disproportionate evidence base and suboptimal interventions. Methods. A ‘best-evidence’ synthesis was conducted to collate the evidence on those ‘black flags’ proposed to be the most important: compensatory systems (worker's compensation and disability benefits), healthcare provider systems and ‘significant others’ (spouse/partner/close family members). A systematic search of scientific and grey literature databases was performed, and the validity and merit of the available evidence was assessed using a system adapted from previous large-scale policy reviews conducted in this field. Results. Following a systematic exclusion process, 65 articles were selected from 1,762 records. Robust, credible and meaningful evidence was found to show that inflexible compensatory systems, a lack of ‘work-focused’ healthcare and communication amongst return-to-work stakeholders, along with inappropriate support from ‘significant others’ are obstacles to work participation for those with low back pain. Conclusions. This is the first attempt at synthesising the evidence on the ‘social’ factors proposed to be important influences on work disability due to low back pain within the Psychosocial Flags Framework. Results have relevance to researchers, policy makers, clinicians and employers, with wider implications for the revision of current psychosocial policy and practice. No conflicts of interest; no funding obtained

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

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Aims

Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

Background and purpose of the study. Uncertainty remains regarding the optimal method of diagnosing sciatica. Clinical guidelines currently recommend that investigations be used only when they are likely to change management. In clinical practice, considerable variation can occur between patient and clinician, regarding the perceived importance of investigations such as MRI scans. The aim of this study was to explore patients' experiences of investigations and to consider the impact of concordance between clinical presentation and investigation findings. Methods and results. In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of sciatica of likely nerve root origin, who had recently undergone investigations, were purposively recruited from an NHS, Primary Care Musculoskeletal Service in the UK. Individual, semi-structured interviews were used to collect data, which were audio-recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Although patients reported wanting investigations to understand the cause of symptoms and inform management, access to them was difficult and protracted. When investigations revealed potentially relevant findings, patients experienced relief, validation, empowerment and decisive decision-making. Disappointment emerged, however, regarding treatment waiting times and options, and long-term prognosis. When investigations failed to identify relevant findings, patients were unable to make sense of their symptoms, move forward in their management or relinquish their search to identify the cause. Conclusion. This study provides the first reported in-depth interpretation of patients' experience of undergoing investigations for sciatica. Important policy and practice implications have been identified for investigation referral criteria; shared-decision-making; information sharing; aligning expectations and managing disappointment. No conflicts of interest. This study was funded by an NIHR Masters in Clinical Research Fellowship awarded to CR. LR is funded, in part, by an NIHR Senior Clinical Lecturer award (Round 3)

Background. Patient-rated measures are the gold standard for assessing spine surgery outcomes, but there is no consensus on the appropriate timing of follow-up. Journals often demand a minimum 2-year follow-up, but the indiscriminate application of this principle may not be warranted. We examined the course of change in patient outcomes up to 5 years postoperatively. Methods. The data from 3′334 consecutive patients (1′789 women, 1′545 men; aged 61±15 years) undergoing first-time surgery between 1.1.2005 and 31.12.2010 for differing lumbar degenerative disorders were evaluated. The Core Outcome Measures Index (COMI) was completed by 3′124 (94%) patients preoperatively, 3′164 (95%) at 3 months follow-up, 3′153 (95%) at 1 year, 3′112 (93%) at 2 years, and 2′897 (87%) at 5 years. 2′502 (75%) completed COMI at all five timepoints. Results. The COMI change-score from pre-op to 3 months follow-up correlated significantly with that from pre-op to 12 months (r=0.65;p<0.0001), 24 months (r=0.57;p<0.0001), and 5 years (r=0.51;p<0.0001). COMI decreased significantly from pre-op to 3 months (3.7-points), and from 3 months to 12 months (0.4-points), then levelled off up to 5 years (0.04–0.05 point-change). The course of change up to 12 months differed slightly depending on pathology/whether fusion was done. Conclusion. Stable COMI scores were seen from 1-year postoperatively onwards. As the early post-operative results appear to herald the long-term outcome, a ‘wait and see policy’ in patients with a poor initial outcome is not advocated. The insistence on a 2-year follow-up could result in a failure to intervene early to achieve better long-term outcomes. No conflicts of interest. No funding obtained

Aims

To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires.

Aims

The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years.

Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America. Clear Management Plan. Mobilisation Schedule. We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management

Aims

Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy.

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.

Aims

HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients’ CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them.

Aim

Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Objectives

To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery.

There is no universally agreed definition of cauda equina syndrome (CES). Clinical signs of CES including direct rectal examination (DRE) do not reliably correlate with cauda equina (CE) compression on MRI. Clinical assessment only becomes reliable if there are symptoms/signs of late, often irreversible, CES. The only reliable way of including or excluding CES is to perform MRI on all patients with suspected CES. If the diagnosis is being considered, MRI should ideally be performed locally in the District General Hospitals within one hour of the question being raised irrespective of the hour or the day. Patients with symptoms and signs of CES and MRI confirmed CE compression should be referred to the local spinal service for emergency surgery.

CES can be subdivided by the degree of neurological deficit (bilateral radiculopathy, incomplete CES or CES with retention of urine) and also by time to surgical treatment (12, 24, 48 or 72 hour). There is increasing understanding that damage to the cauda equina nerve roots occurs in a continuous and progressive fashion which implies that there are no safe time or deficit thresholds. Neurological deterioration can occur rapidly and is often associated with longterm poor outcomes. It is not possible to predict which patients with a large central disc prolapse compressing the CE nerve roots are going to deteriorate neurologically nor how rapidly. Consensus guidelines from the Society of British Neurological Surgeons and British Association of Spinal Surgeons recommend decompressive surgery as soon as practically possible which for many patients will be urgent/emergency surgery at any hour of the day or night.

Cite this article: Bone Joint J 2015;97-B:1390–4

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Cite this article: Bone Joint J 2015;97-B:527–31.