Aims. Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa. Results. Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17). Conclusion. Inter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable. Cite this article: Bone Joint J 2023;105-B(9):1007–1012

Purpose and background. Work-related musculoskeletal disorders, particularly back pain, are a significant issue for healthcare workers, with patient handling being the most frequently reported risk factor. Patient handling is often performed without assistive devices or equipment, which can cause healthcare staff to maintain awkward postures or experience high loads. This review aimed to comprehensively map the literature surrounding manual patient handling (without assistive devices) by healthcare practitioners to identify the current evidence-base on moving and handling of patients and explore what primary research had been conducted. Methods and results. JBI methodology for scoping reviews and an a priori registered protocol (DOI 10.17605/OSF.IO/8PR7A) was followed and AMED, CINAHL, MEDLINE, SPORTDiscus and EMBASE databases were searched. Literature published in English between 2002 and 2021 was included. Forty-nine records were included: 36 primary research studies, 1 systematic review and 12 ‘other’ including narrative and government reports. Primary research predominantly used observational cross-sectional designs (n = 21 studies). Most studies took place in hospitals (n = 13) and laboratories (n = 12). Nurses formed the largest population group (n = 13), with very little research on physiotherapists and other allied health professionals. Conclusion. This scoping review comprehensively reviewed the available literature in the area. Most of the included primary research was observational. Nurses were often investigated in hospitals and laboratories. Qualitative research investigating moving and handling and further biomechanical investigation into therapeutic handling by healthcare staff were identified as areas for further research. Conflicts of interest. None. Sources of funding. None. This work has been published in Physiotherapy: Johnson, K., Swinton, P., Pavlova, A. and Cooper, K., 2023. Manual patient handling in the healthcare setting: a scoping review. Physiotherapy. (120) 60–77 . https://doi.org/10.1016/j.physio.2023.06.003

Background. Low back pain can lead to neuroplastic changes in the central nervous system, known as nociplastic pain. As nociplastic pain may be provoked by premorbid sensory profiles, such profiles may be prognostic in the development of nociplastic pain over time. Objectives. To investigate whether four sensory profiles are prognostic in the development of symptoms of nociplastic pain in people with acute low back pain. Methods. A longitudinal type 2 prognostic factor research study was performed in accordance with the PROGRESS framework, using a baseline and a follow-up after 12 weeks, between the Adolescent/Adult Sensory Profile and the Central Sensitisation Inventory. Study participants were consecutively included from primary care physiotherapy practices randomly spread throughout the Netherlands. A multivariable regression analysis was performed to adjust sensory profiles by the level of pain, disability, age, and duration of low back pain. Results. After adjustment Low Registration B=0.41, 95%CI (0.37, 0.99), Sensory Seeking B=0.37, 95%CI (0.24, 0.73), Sensory Sensitive B=0.51, 95%CI (0.50, 1.06), Sensation Avoiding B=0.46, 95%CI (0.43, 0.99) were significantly associated with the development of nociplastic pain symptoms. Conclusion. Sensory profiles in people with acute low back pain predict symptoms of nociplastic pain after 12 weeks. Conflict of interest: No conflict of interest. Sources of funding: No funding obtained

Objectives. This study aims to investigate whether bacteria are present in intervertebral discs (IVDs) and their influence. Causality between chronic infection of the IVD and its degenerative process gained great interest recently. Granville Smith et al. (2021) identified 36 articles from 34 research studies investigating bacteria in IVDs, from these 27 studies found, Cutibacterium acnes being the most abundant. However, whether bacteria identified were present in vivo or if they represent contamination remains unclear. Methods. Human IVD tissue was fixed in paraffin and Immunohistochemical stained for Gram-positive bacteria. NP cells in monolayer have been stimulated with LPS (0.1–50 µg/ml) and Peptidoglycan (0.1–50 µg/ml) for 24, 48 and 72 hrs to investigate their influence. The concentration of proinflammatory and catabolic cytokines in the media is being measured using ELISA. RNA extracted and RT-qPCR utilised for factors associated with disc degeneration matrix genes, matrix degrading enzymes, cytokines, neurotrophic factors and angiogenic factors. Results. Bacteria were detected within IVD tissue. Bacteria was internalized by the NP cells and influenced the nuclei morphology. Preliminary results of the exposure of NP cells to bacterial components demonstrate that ADAMTS4 as well as IL-8 were showed an increase in gene expression after LPS and peptidoglycan treatment compared to the non-treated control. Underlining these results, IL-8 protein was increased in treated groups, whereas peptidoglycan treated groups showed a dose dependence. Conclusion. This study demonstrates that Gram positive bacteria are present within the IVD. The exposure of NP cells to peptidoglycans indicates that bacterial components trigger a stress response. Conflicts of Interest: No conflict of interest. Sources of Funding: This project is part of the Disc4All Training network to advance integrated computational simulations in translational medicine, applies to intervertebral disc degeneration and funded by Horizon 2020 (H2020-MSCA-ITN-ETN-2020 GA: 955735)

Introduction. The British Spinal Registry (BSR) is a web-based database commissioned by the British Association of Spine Surgeons (BASS) in the UK. It allows auditing of spinal surgery outcomes, patient's safety and overall experience. The clinical data include patient's demographics which is entered into the Registry by medical staff, as well as patient-reported outcome measures (PROM) that is submitted to the Registry by the patient themselves at different time periods post-operatively. It has the ability to register Device and Implants as well as co-ordinate multicentre research. This study is to identify both the staff and patient compliance regarding to data submissions to the BSR at St. George's Hospital NHS Trust. Methods and Materials. Retrospective analysis of the BSR data for all spinal surgeries that was performed at SGH by the three Complex Spinal Surgery Consultants between 1st January 2017 to 31st December 2018. This study period allowed up to 12 months PROM data analysis. Staff and Patient compliance were analysed separately depend on the data they submitted. Results. 404 (n) spinal surgeries were performed over this two-year period. Surgical demographics: 39.4% (159/404) males and 56.2% (227/404) females, 4.5% (18/404) declined to be added. Age ranging from 6 to 92, mean age was 47.9. Staff compliance was 89.4% for the registration of patient data. Trauma and tumour patients were excluded as they are not required to complete any pre-operative PROMs. For the remaining patients, 35.8% (116/324) completed their baseline pre-operative PROMs. A steady decrease in patient compliance for post-operative PROMS was observed: 29.8% (2 weeks), 24.9% (6 weeks), 21.2% (6 months), 17.1% (12 months), and 16.6% (24 months). Conclusions. We identified a poor patient compliance in both pre-operative and post-operative PROMS. Patient questionnaire fatigue can occur over time which results in falling compliance to PROMS in 12 months and 24 months. Moreover, patients who do not provide an email address are less likely to fill in their PROMS. Satisfactory compliance for staff regarding to BSR utilisation are shown. Staff should aim to achieve a higher level of compliance as this will help to keep a record of all spinal surgeries that are performed and any complications that are encountered in a particular centre. Over the past three years, the BSR had introduced various schemes to drive up utilisation including a Best Practice Tariff in 2019. Part of the tariff will be withheld when staff failure to enter patients onto the Registry. Further research is needed to determine why there is such fall off especially with patient compliance and to elucidate potential measures to improve their compliance

Background. Evidence supports that dysfunction of descending inhibition (endogenous analgesic (EA) modulation) contributes towards chronic pain conditions. Research suggests that manual therapy may influence EA modulation; however, this is poorly understood. Trials testing the effect of sustained digital pressure, a commonly used manual therapy technique, using pain pressure threshold (PPT) would give us a better understanding of the influence of manual therapy on EA modulation. A measurement of PPT has been shown to be most effective using fingertip pressure due to the palpatory feedback of symptomatic tissues. Design. A cross-sectional observational study, utilizing a repeated measure approach. Aim. The aim of this research study is to provide preliminary data on the variability of pressure in sustained fingertip pressure in comparison to algometer guided pressure. Methods. Utilizing a pressure algometer, 26 participants were used to test the variability of fingertip pressure in comparison to algometer guided pressure, over 120 seconds. In a randomized order and utilizing two sheets of skin, participants tried to attain, and sustain, a targeted pressure. In the fingertip pressure condition, participants were blinded to the exerted pressure. Conclusion. It was determined that, on average, participants were able to attain the target pressure, but this was highly variable from trial to trial. The test-retest measurement concluded that participants' accuracy was reproducible. Participants were not reproducible in variability when completing the test-retest measurement. There was a relatively higher variability with the lower pressures tested. The order in which the trial was performed, and type of skin did not affect the variability. It was concluded that, whilst some practitioners appear to have a high degree of accuracy with low variability of sustained finger-tip pressure, across a sample population this was not the case bringing into question the mechanism of effect of this common manual therapy technique. Conflict of interest: None. Funding: None

Background. An understanding of the patterns of healthcare services used after MRI of the spine in general practice would provide information about how MRI scans are used in primary care. Aim. To describe the healthcare use of patients referred for lumbar MRI in general practice, and to investigate the association between specific patient characteristics, back pain characteristics and MRI abnormalities with subsequent specialist consultation. Methods. Patients already referred by their general practitioner for MRI of the lumbar spine were recruited. The MRI radiology reports were scored on abnormalities. The questionnaires filled in at baseline, and at 3 and 12-month follow-up, included potential clinical predictors from history taking and use of healthcare services (consultation, surgery). Results. Of the 683 included patients being referred for MRI by their general practitioner, 55% were being referred for consultation with a specialist during the first 3 months of follow-up. Patients with no history of back complaints, severe leg pain, more disability, and/or a history of back surgery had a greater chance of being referred to a specialist. Addition of the reported MRI findings did not add to the predictive value of being referred based on only clinical factors. Conclusion. Our findings suggest that the general practitioners decision whether or not to refer a patient to a specialist was not dependent on the MRI report, but was mostly based on history taking. From a clinical perspective, these results raise questions about the usefulness of the lumbar MRI in general practice patients with low back pain. Conflicts of interest: No conflicts of interest. Sources of funding for the research: This study is partly funded by a program grant of the Dutch Arthritis Foundation. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Background. Recommendations in clinical practice guidelines for non-specific low back pain (NSLBP) are not necessarily translated into practice. Multiple research studies have investigated different strategies to implement best evidence into practice yet no synthesis of these studies is available. Objectives. To systematically review available studies to determine whether implementation efforts in this field have been successful; to identify which strategies have been most successful in changing healthcare practitioner behaviours and patient outcomes. Methods. A systematic review was undertaken, searching electronic databases, hand searching, writing to key authors and using prior knowledge of the field to identify papers. Included papers evaluated a strategy to implement best evidence about management of NSLBP into practice; measured key outcomes regarding change in practitioner behaviour/patient outcomes and subjected their data to statistical analysis. The Cochrane Effective Practice and Organisation of Care (EPOC) recommendations about data extraction and synthesis were followed. Study inclusion, data extraction and study risk of bias assessments were conducted independently. Results. Of 7654 potentially eligible citations, 17 papers reporting on 14 studies were included. Single/one-off implementation efforts were consistently unsuccessful. Increasing the frequency and duration of strategies led to greater success with those continuously ongoing over time the most successful. Risk of bias was highly variable with 7 of 17 papers rated at high risk. Conclusions. One-off implementation strategies may seem attractive but are largely unsuccessful in effecting meaningful change in practice. Increasing frequency and duration of strategies results in greater success and the most successful implementation strategies use consistently sustained interventions

Objectives

Many studies have investigated the kinematics of the lumbar spine and the morphological features of the lumbar discs. However, the segment-dependent immediate changes of the lumbar intervertebral space height during flexion-extension motion are still unclear. This study examined the changes of intervertebral space height during flexion-extension motion of lumbar specimens.

Randomised controlled trials (RCTs) that assessed the efficacy of bracing for adolescent idiopathic scoliosis have suffered from small sample sizes, low compliance and lack of willingness to participate. The aim of this study was to assess the feasibility of a comprehensive cohort study for evaluating both the efficacy and the effectiveness of bracing in patients with adolescent idiopathic scoliosis. Patients with curves at greater risk of progression were invited to join a randomised controlled trial. Those who declined were given the option to remain in the study and to choose whether they wished to be braced or observed. Of 87 eligible patients (5 boys and 63 girls) identified over one year, 68 (78%) with mean age of 12.5 years (10 to 15) consented to participate, with a mean follow-up of 168 weeks (0 to 290). Of these, 19 (28%) accepted randomisation. Of those who declined randomisation, 18 (37%) chose a brace. Patients who were more satisfied with their image were more likely to choose bracing (Odds Ratio 4.1; 95% confidence interval 1.1 to 15.0; p = 0.035). This comprehensive cohort study design facilitates the assessment of both efficacy and effectiveness of bracing in patients with adolescent idiopathic scoliosis, which is not feasible in a conventional randomised controlled trial.

Cite this article: Bone Joint J 2015; 97-B:973–81

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.