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. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

Purpose. Prospectively evaluate the timescale of leg pain resolution after lumbar discectomy and decompression, in the immediate post-operative period and identify possible risk factors for failure/delay in leg pain resolution. Materials and Methods. A prospective observational study of 100 consecutive patients undergoing lumbar discectomy or decompression. Patients recorded their leg and back pain in VAS and disability in ODI preoperatively. Patients rated their leg pain relief just prior to discharge after surgery. Telephone follow-up at 1-2 week and 3-4 week post-op was followed by clinic review at 6 and 12 weeks, to assess the timescale of leg pain resolution and improvement in function (ODI score). Results. Immediately before discharge from hospital 67% patients reported relief of leg pain. 33% reported no relief or were unsure. Of these, 26 (80%) reported pain relief subsequently. At 1-2 weeks, 81 patients reported pain relief. 14 reported persistent pain, but six of them (45%) improved subsequently. By six weeks 91% reported leg pain relief and only two of the unimproved nine patients subsequently experienced relief of leg pain. Failure to improve the leg pain was clearly associated with failure to improve disability by ODI score. But the ODI score did not improve in 11 patients reporting relief of leg pain. Decompression in older age and women had a relatively higher risk of poor result. Conclusion. After lumbar discectomy and decompression, leg pain relief is immediate in 67%, in 81% by one week and in 91% by six weeks. Improvement is unlikely after this period. Non-resolution of leg pain resulted in persistent/worsened disability, but 11% patients did not improve functionally despite experiencing leg pain relief. Decompression, older age and female sex were negative risk factors

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

Aims. Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain. Results. There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group. Conclusion. This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81–7

Aim. The primary aim of this pilot study was to assess and evaluate the SpineCor Pain Relief Brace as a method of reducing the pain experienced by patients diagnosed with degenerative scoliosis. Method. Participants (n=24) with an average age of 67 (+/− 8) old that fulfilled the study inclusion criteria were randomly allocated into either a treatment or control group. Both sets of participants received questionnaires (ODI, SF 36v2 and EQ5D-5L) at 1,3,6,9 and 18 months. In addition to the questionnaires the treatment group also received the SpineCor Pain Relief Brace and took part in a semi structured interview. Results. The results from the trial were mixed; repeated measures analysis on the quantitative data showed the brace had a small effect on reducing reported pain and increasing activity. Results from the semi-structured interviews were more informative. Analysis revealed the brace enabled patients' to participate in activities at a higher intensity. Problems with the functionality of the brace such as toileting that ultimately limited the amount of time they could wear the brace were also identified. Conclusion. Overall, mild pain relief and improvements in functionality and activity levels were reported in addition to several functional problems with the brace. These problems could be attributed to the average age of the participants. No prior work has examined issues related to wearing a brace from the patient perspective. Further work is needed to develop a better understanding of the benefits and limitations of bracing for Degenerative scoliosis. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

We have studied 58 patients with pain from osteoporotic vertebral fractures which did not respond to conservative treatment. These were 53 women and five men with a mean age of 72.5 years. They received a nerve-root injection with lidocaine, bupivicaine and DepoMedrol. The mean follow-up period was 13.5 months.

The mean pain scores before treatment, at one and six months after treatment and at the final follow-up were 85, 24.9, 14.1, and 17.4, respectively. According to our modified criteria for grading results, six patients were considered to have an excellent result, 42 good and ten fair. A newly developed compression fracture was noted in three patients. There were no complications related to the injection.

Our study suggests that nerve-root injections are effective in reducing pain in patients with osteoporotic vertebral fractures and that these patients should be considered for this treatment before percutaneous vertebroplasty or operative intervention is attempted.

We performed intercostal nerve transfer in 19 patients to relieve pain from preganglionic injury to the brachial plexus. The procedure was successful in 16 patients at a mean of 28.6 months (12 to 68) after the injury.

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Background. BANDAIDE aka Back and Neck Discomfort relief with Altered behaviour, Intelligent Postures, Dynamic movement and Exercises (ISBN - 0995676933) is a concise self-help booklet containing strengthening exercises and illustrated information to enable patients self-manage their back and neck pain. The aim of this preliminary audit was to determine patient opinion on BANDAIDE. Institutional audit approval was obtained – No. 8429. Methods and Results. BANDAIDE was distributed to 40 patients, who were asked to evaluate the booklet using the Usefulness Scale for Patient Information Material (USE). USE consists of nine positive statements which are subdivided into three sub-domains; cognition, emotional and behavioural. The cognition sub-domain assesses the knowledge obtained from the material, the emotional sub-domain evaluates the effects of the material on an individual's ability to cope with the illness and the behavioural sub-domain assesses ability to self-manage. Responders were required to rate the extent to which they agreed with each of the nine statements on a scale of 0 to 10, where 0 denotes ‘completely disagree’ and 10 denotes ‘completely agree’. Each subsection is on a scale of 0–30, with a higher score suggesting better usefulness. 23 participants provided their opinions of BANDAIDE through the USE. For the three sub-domains, the mean ratings for cognition, emotional and behavioural were 27.2, 24.7, and 26.4 respectively. Conclusions. This preliminary audit suggests that BANDAIDE provides coherent advice that enables a patient to self-manage their back and neck pain. Nevertheless, the opinions of a larger cohort should be pursued to obtain more robust conclusions. Conflict of Interest: George Ampat sells the BANDAIDE booklet online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Bandaide is a trading name. Shantanu Kundu is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

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

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

Although interlaminar endoscopic lumbar discectomy (IELD) is considered to be less invasive than microscopic lumbar discectomy (MLD) in treatment of lumbar herniated nucleus pulposus, the radiologic change of multifidus muscles by each surgery has rarely been reported. The aim of the present study was to compare the quantitative and qualitative changes of multifidus muscles between two surgical approaches and to analyze the correlation between various parameters of multifidus muscles and long term surgical outcome. 21 patients who received MLD and 18 patients who received IELD in a single tertiary hospital were enrolled and their preoperative, postoperative (≤15 days), and follow-up (≥6 months) MRIs were analyzed. The cross-sectional area (CSA) and fatty degeneration rate (FD) were quantitatively estimated at the level of surgery. The correlations among CSA, FD, body mass index, follow-up visual analogue scale(VAS) and Oswestry Disability Index(ODI) were assessed. Mean intervals of postoperative MRI and follow-up MRI from surgery were 3.0±3.7 days and 14.5±10.7 months, respectively. During the follow-up period, VAS was improved from 7.1±1.3 to 2.1±1.8 in MLD and from 8.2±1.4 to 2.2±1.8 in IELD. In cases of MLD, comparing with preoperative MRI, ipsilateral CSA was significantly increased in postoperative MRI (795.6mm. 2. vs. 906.5mm. 2. , p<0.01), but it was not significantly different in follow-up MRI (795.6mm. 2. vs. 814.4mm. 2. , p=1.00). However, in case of IELD, the ipsilateral CSAs in preoperative, postoperative, and follow-up periods were 892.0 mm. 2. , 909.3 mm. 2. , and 900.3 mm. 2. , respectively. These changes were not significant over time (p=0.691). The ipsilateral FDs were not significantly changed between preoperative and follow-up periods in both MLD (21.4% vs. 20.9%, p=0.81) and IELD groups (23.5% vs. 21.8%, p=0.19). The increment of ipsilateral CSA had significant correlations with follow-up ODI (r=−0.368, p=0.02). Comparing with IELD, MLD induced more surgical trauma on multifidus muscle in postoperative period, but the muscular damage was recovered in follow-up period. IELD can minimize surgical trauma on multifidus muscle showing similar pain relief as MLD. Favorable surgical outcome in follow-up period may be related to increment of multifidus muscle volume. Figure 1. (A-C) The multifidus muscles in preoperative, postoperative, and follow-up periods, respectively, in patient with MLD. Comparing with preoperative period, the CSA of right multifidus muscle (ipsilateral side) was increased in postoperative period, but recovered in follow-up period. (D-F) The multifidus muscle in preoperative, postoperative, and follow-up periods, respectively, in patient with IELD. The CSA of left multifidus muscles (ipsilateral side) was not significantly changed over time. Comparing preoperative MRIs with follow-up MRIs, the FDs of multifidus muscles were not significantly changed regardless of surgical technique. Figure 2. The CSA was measured by marking region of interest (ROI) and FD was measured by calculating the rate of pixels beyond the threshold in ROI. All measurements were performed using ImageJ software (version 1.52a, National Institutes of Health, Bethesda, Maryland, USA). For any figures or tables, please contact the authors directly

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

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

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Aims

This study aimed, through bioinformatics analysis and in vitro experiment validation, to identify the key extracellular proteins of intervertebral disc degeneration (IDD).

Objective. To identify any difference in clinical outcome between Intra-Capsular facet (IF) and Peri-facet (PF) injections in patients with low back pain (LBP). IF and PF joint steroid injections have been used for treatment of LBP with varied reports of pain relief for many years. Methods. Patients randomised into IF and PF groups. Bilateral L4/5 and L5/S1 levels injected. 40mg of Depo-Medrone with Lignocaine (total 1ml) in IF group. 80mg of Depo-Medrone with 1ml of 0.5% Chirocaine (total 3ml) in PF group. Pain visual analogue score (VAS) and analgesic chart – completed till six months. Results. Eighty eight total, 14 withdrew, 69 with feedback available. Sixty-three (91%) had significant pain relief a week following injection, 86% and 94% in IF & PF groups. Mean duration of pain relief was 12.4 weeks (IF-12.2, PF-12.5). Mean change in VAS before & after injection was 4 (IF-4, PF-4). Mean change in analgesic use before & after injection was 2 tablets. (IF-2.9, PF-2.3). Radiation dose area product (DAP) for IF injections- 603 and PF- 45 mGy.cm. 2. 45 (51%) came for repeat injections, 19 & 26 in IF & PF groups. Conclusions. Majority of patients had pain relief with no statistically significant difference between 2 groups in change in pain severity, duration of pain relief or change in analgesic intake. Significant change in VAS after injection in both groups (from 7 to 3). Pain relief for a mean duration of 12.4 weeks. PF - technically easier- 9 patients randomised to IF group had to have PF injections (facet joint osteophytes). Radiation doses much higher for IF injections even in expert hands (P=0.007). It took double the time to perform IF injections compared to PF (30 and 15 minutes)

Aims

The aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.

Aims

Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse.