Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management. . Cite this article: Bone Joint J 2014;96-B:717–23

Objectives. This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication. Design. A single group retrospective analysis. Participants. Data from 54 participants with non-specific low back pain (Male = 26. Female =28, mean age 43.7yrs) who attended a four week functional restoration programme between September 2012 and June 2013 were analysed. Results. There was a statistically significant improvement between Oswestry Disability Index and Pain Self Efficacy scores before and after the treatment intervention, and at 9 month follow-up (p<0.001). When only scores at the end of the treatment intervention and month 9 were compared there was no significant difference (p=0.184 for ODI, p=0.341 for PSEQ). Patients also self-reported reduced reliance on analgesic medication after the treatment intervention and at 9 month follow-up. Conclusion. The findings indicate that a group based multidisciplinary functional restoration programme for patients with persistent low back pain, which targets modifiable obstacles to recovery, can be effective in reducing disability, improving self-efficacy and reducing reliance on medication in both the short and medium term. This article has also been published online in Wiley Online Library (. wileyonlinelibrary.com. ) DOI: 10.1002/msc.1078 in Musculoskeletal Care Journal (2014) © 2014 John Wiley & Sons, Ltd. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose. Cognitive Muscular Therapy (CMT) is a new treatment for low back pain which integrates psychological techniques for pain management alongside training to improve postural control. Rather than focus on postural alignment or strength, CMT aims to improve the regulation of postural tone (low-level activity which supports the body against gravity). This is achieved by teaching patients an awareness of compensatory paraspinal activation, which can be triggered by overactivity of the abdominal muscles. The aim of this study was to understand whether CMT could reduce symptoms associated with low back pain and improve paraspinal muscle activation. Methods and results. Fifteen patients with chronic low back pain received seven weekly sessions of CMT from a physiotherapist. Clinical data was captured at baseline and two weeks after the intervention using the Roland-Morris questionnaire and the pain catastrophising scale. Activation of the erector spinae muscle during walking was also measured at baseline and after the final intervention session. Change data were analysed using paired t-tests. There was a 75% reduction (p<0.001) in the Roland-Morris score from a mean (SD) of 9.3(2.9) to 2.3(2.6), along with a 78% reduction in pain catastrophising (p<0.002) from 16.6(13) to 3.7(4.8). Activation of the contralateral erector spinae muscles reduced by 30% (p<0.01) during the contralateral swing phase of walking. Conclusion. In this small sample, CMT delivered large clinical improvements and reduced activation of the low back muscles during walking. Larger randomised trials are now required to confirm whether CMT could outperform existing physiotherapy treatments for chronic back pain. Conflict of interest. No conflicts of interest. Source of funding. University of Salford

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)

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

Purpose and background. Understanding patients’ expectations of back pain treatment can help improve their experiences, adherence and outcomes. Patients typically expect a diagnosis and exercise-based physiotherapy, but often undervalue the role of psychological factors. This study explored patients’ expectations of outpatient physiotherapy treatment for back pain in primary care. Methods and Results. The design, a secondary analysis of a qualitative cross-sectional study, involved 25 patients (13M:12F), aged 20–81, referred with low back pain (duration 7 weeks to 9 years). This sample did not include patients with serious spinal pathologies, known psychological disorders, or those unable to communicate without assistance. Face-to-face interviews were undertaken in patients’ homes, which were audio-recorded, transcribed verbatim and analysed using the six stages of thematic analysis outlined by Braun and Clarke. Patients expected a caring clinician and a strong therapeutic relationship, where they felt believed, openly communicated with and valued as an individual. Most patients expected a diagnosis and credible explanation for their pain. There was an almost equal split between those keen to take responsibility for their care and those who felt this was the clinicians’ role. Expectations of passive therapies were slightly higher in this study than existing research. Most patients were realistic about outcomes and expected treatment to reduce their pain, but not cure it. Conclusion. A positive experience mattered most to patients, valuing the relational aspects of their care more than the clinical content provided. Patients saw back pain through a biomedical lens, and most failed to recognise the role of psychosocial factors in their condition or treatment. Conflicts of interest. None. Sources of funding. Funding for primary data: Arthritis Research UK (now Versus Arthritis)

Background. Various studies have highlighted issues regarding the prevalence of back pain due to lead apron use. The health and safety executive guidelines on personal protection equipment state that an employee should be able to carry the weight of a lead apron without injury (HSE, 2017). It has been suggested that wearing a 15 pound lead apron can place pressures of up to 300 pounds per square inch of the intervertebral discs (Khalil, 1993), ‘interventionalist's disc disease’ has been identified as a confirmed entity (Ross et al. 1997). Aim. To evaluate the prevalence of back pain amongst theatre staff and correlate this to lead apron use. Methods. Data collection (November 2018 – February 2019) involved the distribution of questionnaires to staff using lead aprons on a routine basis at Salisbury District Hospital. Results. A total of 59 members of staff responded to the questionnaire. The results showed that 30% staff had a previous history of back pain, of these 61% felt that their back pain had worsened since wearing lead aprons. 46% of staff who did not have any previous history of back pain developed new back pain since wearing lead aprons. A total of 46% of staff feel that their back pain has been exacerbated or caused by lead apron wearing. Conclusion. The study highlights that a significant proportion of staff had new or worsening back pain due to lead apron use. This can lead to time off work and could lead to unsafe practice around ionising radiation. No Conflicts of interest No funding obtained

Background and purpose. Trajectories of change over time can illustrate the course of pain. Back pain trajectories have previously been identified among adults. Understanding different patterns of back pain among adolescents could shed light on how persistent back pain develops. We aimed to identify and compare trajectories of back pain among adolescents in the general population. Methods and results. This prospective cohort study followed 1,336 adolescents (initially aged 11 years) every three months for three years, using self-completion questionnaires. Latent class growth analysis was used to cluster subjects into distinct trajectories of back pain. Six clusters were identified. Most subjects (78%) had very low likelihood of back pain throughout follow-up. The second largest cluster (10%) had relatively low and falling probability of back pain. Two clusters (4% each) showed increasing probability of back pain. One cluster had a peak likelihood of pain around age 13 (2%). The smallest cluster (1%) had very high probability of back pain throughout follow-up. The more painful trajectories had significantly fewer males, higher levels of depression and somatization, and lower life satisfaction at baseline, but differed little in physical activity or BMI. Conclusions. Over a fifth of adolescents had trajectories indicating back pain, but a minority had persistent pain problems. Poorer baseline psychological status and female gender were linked with more frequently experienced pain. Trajectories indicating rising or persistent pain might be illustrating the beginning of a long-term pain problem. Headache, facial pain and stomach pain trajectories were also identified in this sample; findings were similar to back pain

Purpose and background. Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation. Patients and methods. Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given. Results. The mean duration of consultation was 38 minutes 59 seconds (range 26:21–53:16). Advice was given in 88% (n=22/25) consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to ‘move your back’ despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and the use of heat. Gaps were identified in the completeness of the advice given and there was a lack of specificity, especially relating to the frequency of recommended tasks and activities. Conclusion. Advice and reassurance are integral to enabling people to self-manage their back pain. Despite its importance, little is known about the advice offered by clinicians. This novel, observational study identifies the topics of advice given by clinicians in back pain consultations and recognises the need for guidance to be patient-centred and specific. No conflicts of interest. Sources of funding: The data were collected as part of Lisa Roberts's Arthritis Research UK academic fellowship [17830]. Lisa Roberts currently holds an NIHR senior clinical lectureship (round 3)

Purpose and Background. Patients with low back pain are increasing globally. Physical dysfunction and psychosocial factors such as stress, anxiety, and fear of movement, often referred to as yellow flags, play a role in the persistence of low back pain. What is not known is the extent to which yellow flags are screened for and treatment adjusted accordingly by Physiotherapists in India. The aim was to determine the current knowledge and awareness of physiotherapists in India regarding psychosocial factors for managing patients with low back pain. Methods. Semi-structured interviews gathered data from of six physiotherapists, The interviews were conducted online. The data was transcribed and analysed using thematic analysis. Results. The main finding was that the physiotherapists in India had a limited knowledge regarding psychosocial factors for management of low back pain. They were not supportive of adding yellow flag screening into their routine treatments due to lack of t awareness of such screening tools Physical elements of low back pain were focused on during treatment by the therapists and recommended by management. The physiotherapists noted that high daily patient volume left them with limited time to alter treatment protocols. Conclusion. There appears to be limited information and education delivered to the physiotherapists in India regarding psychosocial factors for managing low back pain. The addition of these factors in the education and treatment protocols could address these important factors when managing patients with low back pain in India. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose and Background. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain. The aims were: 1/ to assess how patients with low back pain respond to osteopathic treatment, both before and after an osteopath has completed a Biopsychosocial Pain Management (BPM) course; and 2/ to assess if it is feasible and acceptable for osteopath participants to receive weekly SCED data and use it to guide patient management. Methods and Results. A multiple baseline single case experimental design trial (. clinicaltrials.gov. , on 18/10/2021, ID number NCT05120921) with 11 UK osteopaths was conducted. Patients were randomised to early, middle or late treatment start dates. Statistical analysis assessed the change between baseline, intervention and follow-up periods. Primary outcomes were the Numeric Pain Rating (NPR) and Patient Specific Function Scales (PSFS), measured during the baseline, the 6-week intervention, and during a 12-week follow-up period. At baseline, the osteopaths reported stronger biopsychosocial attitudes to pain, compared to biomedical beliefs (PABS: 34 behavioural scale; 29 biomedical scale). Overall, patient participants showed daily increases in symptoms during the pre-treatment phase (+0.24/day, p<0.001), and daily decreases during treatment (−2.94 over the treatment phase, p<0.001), which continued post-treatment (−3.36 over 12 weeks, p=0.04). Similar improvements were observed for function. Conclusion. Osteopathic care was shown to help patients with persistent low back pain. Patient recruitment was challenging because of the randomisation. With further development, the method shows feasibility as a means of enhancing research activity among practising clinicians. Previous presentations or publications of the work. The protocol was published (. https://doi.org/10.1016/j.ijosm.2023.100660. ) and presented at SBPR in 2022. The results were presented to an osteopathic conference in October 2023. Ethics approval was received from the University College of Osteopathy Research Ethics Committee. Conflicts of interests. Jerry Draper-Rodi receives fees from the sales of the e-learning course on the biopsychosocial management on the UCO CPD platform. Sources of funding. The research was funded by the Osteopathic Foundation

Purpose and background. Although low back pain (LBP) with leg pain, is considered by most a poor prognostic indicator, it is at the same time believed to have a favourable natural resolution, and is often treated along similar lines to non-specific LBP, in line with current guidelines. It is unclear whether patients with LBP and leg pain are a distinct subgroup that might benefit from early identification and targeted interventions. We set out to investigate the impact of LBP with leg pain on health outcomes and health resources compared with that of LBP alone, and to explore which factors contribute to the observed disability outcomes. Methods. A systematic literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1994 to 2009. Results. Of the 89 papers retrieved, 9 were included in the review. The heterogeneity of data allowed only for narrative analysis of findings. All studies reported worsening baseline health status in terms of poorer self-assessment and increasing use of health care the further the radiation of leg pain. Differences in quality of life measures were higher for physical than for mental health dimensions. Pain and disability outcome at follow up assessment appeared to be less favourable in this group than for individuals with LBP alone. Conclusion. LBP with leg pain is associated with poorer health outcomes and increased use of health resources. These findings argue for early identification of these cases by health care professionals and for pursuing effective treatments rather than simply treating similarly to non-specific LBP

Purpose and background. Lower back pain is a leading cause of disability and a common condition seen by osteopaths. Evidence and advice for the safest lifting posture vary, as do healthcare practitioners' attitudes towards back pain. The aim of this study was to understand osteopaths' beliefs about safe lifting postures, their attitudes towards back pain, and to compare these findings with published data from physiotherapists and manual handling advisors. Methods and results. A cross-sectional electronic survey was used to invite a sample of UK osteopaths to select images that best represent their perception of safe lifting posture (straight or rounded back), and to complete the Back Pain Attitudes Questionnaire (Back-PAQ, Appendix 1). Data was analysed to assess lifting posture selection and relationship to back pain attitudes. 46 (85.2%) out of 54 osteopaths selected straight back posture as safest, these participants had significantly more negative attitudes to back pain injury (i.e. higher Back-PAQ scores), than the 8 osteopaths who selected a rounded back posture (p = 0.007). Data from 266 physiotherapists and 132 manual handling advisors revealed an overall agreement about straight back lifting posture, however revealed differences in Back-PAQ attitude between the professions. Conclusion. Despite a lack of evidence base and inconsistent recommendations, osteopaths in this survey and other healthcare practitioners believe that straight back lifting posture is the safest. Practitioners' attitudes vary and are known to influence their patients' attitudes and recovery behaviour. Further research is recommended to identify reasons for different beliefs, and their impact on advice-giving and patient outcomes. Conflicts of interest: None. Sources of funding for the research: None

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain

Purpose. To determine, for the first time, how back pain is portrayed in the United Kingdom press. Methods and Results. LexisNexisTM Professional search engine was utilised to retrieve articles from all national newspapers over a six months containing the terms “back pain/backpain/back ache/backache” from May to October 2009. 284 relevant articles were retrieved. Of these tabloids accounted for 62% and broadsheets for 38%. Back pain was the sole topic in 7%, a main topic in 18% and mentioned in passing in 75%. 15% were essentially case reports and the tone was neutral in 95%, positive in 2.5% and negative in 2.5%. The cause of back pain was mentioned in 11% of articles- trauma accounted for 50% and disc disease and spinal deformity for 20% each. Only 0.3% of articles discussed litigation. Articles mentioned new physiotherapy regimes in 7%, new forms of alternative therapy in 7%, new surgical techniques/technologies in 2% and new medications in 1%. They were significantly more likely to mention new non-surgical techniques- Fishers' Exact Test p=0.01. Articles were alternative therapy related in 3%, physiotherapist related in 2%, surgeon related in 1% and pain specialist related in 1%. 10% of papers included a quote from an “expert” of which 23% were Spine Surgeons, 16% GP's, 13% Sports Physicians, 13% alternative therapists, 10% pain specialists and 7% physiotherapists. Overall, 98% of articles were of a neutral tone and 1% were of a positive tone or negative tone. Articles concerning physiotherapists or new surgical techniques/technologies were significantly more likely to be of a positive overall tone than the other articles- Fishers' Exact Test p=0.04. Conclusions. Back pain receives a considerable amount of attention in the United Kingdom press. Much of this currently concentrates on isolated case reports, the aetiology of back pain is poorly represented, quoted “experts” are frequently non-medical and new surgical treatments receive significantly less attention than new non-surgical treatments. The press play an important role in educating and informing the general public. The stories they cover ad how they cover them have a powerful influence on public perceptions. We need to do more to engage with the press and positively influence their reportage

Purpose. Clinical guidelines identify a clear role for managing back pain with structured exercise. Pilates is a commonly recommended modality, however, Pilates-specific research is limited. Research suggests the patient-practitioner relationship may be important in managing persistent low back pain, although further research is needed to evaluate its impact on outcomes. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain. Methods and Results. This qualitative study used a multi-site, ethnographically-informed methodology. Data collection included observation of 24 Pilates sessions at eight sites across the South of England, and 19 semi-structured interviews with Pilates teachers and clients with persistent low back pain. Data were audio-recorded, transcribed verbatim and analysed thematically. From the interviews and observations, ten themes emerged, of which four related to components of the relationship: (1) ‘being known’; (2) support; (3) teacher expertise; and (4) mastery of exercises, facilitated by the teacher. Key influences on the relationship were identified in four themes: (5) professional identity of Pilates teachers; (6) health perceptions; (7) social influences such as group dynamic; and (8) service perceptions. An additional two themes described the perceived impact of the relationship: (9) feelings of safety; and (10) ‘feeling good’. Conclusion. These findings demonstrate the complex, multi-faceted interaction that occurs during Pilates sessions that includes instruction, demonstration, verbal and tactile feedback. This study illustrates the perceived importance of Pilates teachers in providing a safe environment for clients with persistent low back pain to exercise. No conflicts of interest. No funding obtained

Purpose. This review aims to explore the methodologies used for estimating the direct and indirect costs attributed to back pain in developed countries. Methods. Six databases were searched to uncover studies about the direct and indirect costs of back pain published in English upto November 2016. Data extracted included study characteristics, cost categories and analysis methods. Results were synthesised descriptively. Results. The search identified 8009 potential studies, of which 40 were included for data extraction. The included studies reported data from 14 industrialised countries with considerably varying methodologies. Most of the studies (n=25) followed a retrospective study design and cost perspective was largely societal (n=26). Nearly half of the selected studies included indirect costs in their analysis as well as direct costs; and the proportion of indirect costs in most of the studies far outweighed the direct costs (3:1 ratio). The analysis method used most frequently was the top-down approach (n=13) followed by bottom-up approach (n=7) and econometric methods (n=7). Inpatient costs and absenteeism costs were the most important cost drivers accounting for 12%−35% of the direct costs and 5%−67% of the indirect costs respectively. The healthcare costs associated with back pain in the UK were estimated at £1.6 billion in 1998 while the indirect costs ranged from £5 billion to £10.7 billion. Conclusions. This is the first methodological systematic review assessing the costs of back pain. Despite differences in methodology, the economic burden of back pain is significant. Development of guideline and standardisation of methodologies is needed for future studies. Conflict of interest: None. Sources of funding: None

Objective. Low back pain (LBP) is a common debilitating condition with great socioeconomic impact. Identifying individuals at risk of LBP is challenging. We have shown IgG N-glycans are associated with LBP. Herewith, we used polygenic risk scores (PRS) from IgG-glycome to test predictability for LBP. Methods. Clusters of IgG-glycans were identified using weighted correlation network approach in TwinsUK (n = 4246). Genome-wide association studies were carried out for the clusters and top associated SNPs (p<5e-8) were extracted. Weighted PRS was calculated as the sum of the number of copies of effect allele from GWAS multiplied by their effect size using the UK Biobank data (n = 350000). The predictive capacity of the PRS for back pain in UK Biobank was estimated using logistic regression. Results. Multiple SNPs were found to be associated with the glycan clusters near genes known to be involved in glycosylation and the inflammatory response (e.g. ST6GAL1, B4GALT1, FUT8). A total of 175 SNPs was used to calculate weighted PRS. In UK Biobank the PRS was a statically significant, but poor, predictor of the risk of back pain (β = 0.126±0.050, p = 0.015, R. 2. = 2.6e-5). The SNPs on chromosome 14 in regulatory regions of FUT8 gene, one of the key governors of core fucosylation, were found to be significantly associated with back pain in UK Biobank (FDR-adjusted p-value < 0.05). Conclusions. These pilot data suggest that genetic component of glycosylation may be associated with the risk of LBP; however, its predictive ability is poor. Conflict of Interest: YSA is a co-owner of Maatschap PolyOmica. GL is a founder and CEO of Genos Glycoscience Research Laboratory. MBF and FMKW declare no conflict of interests. Sources of Funding: The research has been supported by the EC FP7 project PainOmics (grant agreement #602736) and conducted using the UK Biobank Resource (project # 18219)

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). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

The National Institute for Health and Care Excellence has issued guidelines that state fusion for non-specific low back pain should only be performed as part of a randomised controlled trial, and that lumbar disc replacement should not be performed. Thus, spinal fusion and disc replacement will no longer be routine forms of treatment for patients with low back pain. This annotation considers the evidence upon which these guidelines are based. Cite this article: Bone Joint J 2017;99-B:1003–1005