Purpose of study and background. Spinal surgery is a high-risk surgical speciality, a patient's understanding of surgical interventions, alternative treatment options, and the benefits and risks must be ascertained to gain informed consent. This pilot study aims to evaluate if the provision of a digital recording of a patient's consultation enhances patient satisfaction, improves recall of clinical diagnosis, recall of treatment options and the risks and benefits of Spinal Surgery. Methodology and results. A coalition team was identified. A safe and secure process for recording and storage identified. Both qualitative and quantitative data was collected via questionnaires. 62 patients were invited to participate in the pilot, 12 declined. Data was collected immediately post consultation, and two weeks following the consultation via telephone. Comparison was made of the relative increase or decrease in patient recall of the clinical diagnosis, treatment options, and the benefits and the risks of spinal surgery. Patient satisfaction was measured pre- and post- consultation. 50 patients (81%) participated. 32 participants (52%) responded to follow up questionnaire at 2 weeks. Recall of risk for surgical intervention increased by 37%, and of benefit by 36%. Patient satisfaction was rated excellent or very satisfied in 93% at initial consultation and at 2 week follow up all participant's rated satisfaction as excellent or very satisfied. Conclusion. This pilot study was small. COVID delayed further recruitment. Initial outcomes demonstrated high levels of patient satisfaction and appear to demonstrate improved recall. Significant technological issues were identified. Further collaborative work needs to be undertaken. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

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

Aims. The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL). Methods. A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups. Results. On the basis of cluster analysis of the SRS-22r subscores, the pooled subjects were divided into three HRQOL groups as follows: almost normal (mean 4.24 (SD 0.32)), mildly disabled (mean 3.32 (SD 0.24)), and severely disabled (mean 2.31 (SD 0.35)). Except for CAM-GL, all the alignment parameters differed significantly among the cluster groups. The threshold values of key alignment parameters for severe disability were TPA > 30°, C2-7 lordosis > 13°, PI-LL > 30°, PT > 28°, and knee flexion > 8°. Lumbar spinal stenosis was found to be associated with the symptom severity. Conclusion. This study provides evidence that the three grades of sagittal compensation in whole body alignment correlate with HRQOL scores. The compensation grades depend on the clinical diagnosis, whole body sagittal alignment, and lumbar spinal stenosis. The threshold values of key alignment parameters may be an indication for treatment. Cite this article: Bone Joint J 2020;102-B(10):1359–1367

Background:. Identification of nerve root involvement (NRI) in patients with low back-related leg pain (LBLP) can be challenging. Diagnostic models have mainly been developed in secondary care with conflicting reference standards and predictor selection. This study aims to ascertain which cluster of items from clinical assessment best identify NRI in primary care consulters with LBLP. Methods:. Cross-sectional data on 395 LBLP consulters were analysed. Potential NRI indicators were seven clinical assessment items. Two definitions of NRI formed the reference standards: (i) high confidence (≥80%) NRI clinical diagnosis (ii) high confidence (≥80%) NRI clinical diagnosis with confirmatory magnetic resonance imaging (MRI) findings. Multivariable logistic regression models were constructed and compared for both reference standards. Model performances were summarised using the Hosmer-Lemeshow statistic and area under the curve (AUC). Bootstrapping assessed internal validity. Results:. NRI clinical diagnosis model retained five items. The model with MRI in the reference standard retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests, neurological deficit (myotome, reflex or sensory). NRI clinical diagnosis model was well calibrated (p=0.17) and discrimination was AUC 0.96 (95%CI: 0.93, 0.98). Performance measures for clinical diagnosis plus confirmatory MRI model showed good discrimination (AUC 0.83, 95% CI: 0.78, 0.86) but poor calibration (p=0.01). Bootstrapping revealed minimal overfitting in both models. Conclusion:. A cluster of items identified NRI in LBLP consulters. These criteria could be used clinically and in research to improve accuracy of identification and homogeneity of this subgroup of low back pain patients

Background. Criticisms about overuse of MRI in low back pain are well documented. Yet, with the exception of suspicion of serious pathology, little is known about factors that influence clinicians' preference for MRI. We investigated the factors associated with physiotherapists' preference for MRI for patients consulting with benign low back and leg pain (LBLP) including sciatica. Methods. Data were collected from 607 primary care patients consulting with LBLP and assessed by 7 physiotherapists, in the ATLAS cohort study. Following clinical assessment, physiotherapists documented whether he/she wanted the patient to have an MRI. Factors potentially associated with clinicians' preference for imaging were selected a priori, from patient characteristics and clinical assessment findings. A mixed-effect logistic regression model examined the associations between these factors and physiotherapists' preference for MRI. Results. Physiotherapists expressed a preference for MRI in 32% (196/607) of patients, of whom 22 did not have a clinical diagnosis of sciatica (radiculopathy). Factors associated with preference for MRI included; clinical diagnosis of sciatica (OR 4.23: 95% CI 2.29,7.81), greater than 3 months pain duration (OR 2.61: 95% CI 1.58,4.30), high pain intensity (OR 1.24: 95%CI 1.11,1.37), patient's low expectation of improvement (OR 2.40: 95% 1.50,3.83), physiotherapist's confidence in the diagnosis (OR 1.19: 95% CI 1.07,1.33) with greater confidence associated with higher probability of preference for MRI. Conclusion. A clinical diagnosis of sciatica and longer symptom duration were most strongly associated with physiotherapists' preference for MRI. Given current best practice guidelines, these appear to be justifiable reasons for wanting patients to have an MRI. Conflicts of interest: None. Funding. SE was supported through an NIHR internship linked to an NIHR Research Professorship awarded to NEF (RP-01-015). NEF is an NIHR Senior Investigator. KK is supported through a HEFCE Senior Clinical Lecturer award. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health

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.

Background. Recruitment to time and target in clinical trials is a key challenge requiring careful estimation of numbers of potential participants. The SCOPiC trial ((HTA 12/201/09) (ISRCTN75449581)) is investigating the clinical and cost-effectiveness of stratified care for patients with sciatica in primary care. Here, we describe the approaches followed to achieve recruitment of our required sample size (n=470), the challenges encountered and required adaptations. Methods. We used recruitment data from the SCOPiC trial and its internal pilot, to show the differences between estimated and actual numbers of patients from consultation to participation in the trial. Patients were consented to the trial if they had a clinical diagnosis of sciatica (with at least 70% confidence) and met the trial eligibility criteria. Results. Initial recruitment estimates suggested we needed a source population of 146,000 adults registered at approximately 30 GP practices, and a monthly trial recruitment target of 22 patients per month over 22 months. The internal pilot trial phase resulted in revisions of these estimates to 256,000 and 42 GP practices. To date, 1,623 patients have been screened for eligibility and 450 randomised. The main reason for ineligibility is low confidence in the diagnosis of sciatica. Conclusion. Our experience highlights the challenge of recruitment to clinical trials of sciatica, particularly in terms of case definition, and the need for careful planning and an internal pilot phase prior to a main trial. We believe our experience will be helpful to others conducting trials with sciatica patients. No conflicts of interest. Funding. NEF is an NIHR Senior Investigator. KK is supported through a HEFCE Senior Clinical Lecturer award. The SCOPiC trial is funded by the National Institute for Health Research Health Technology Assessment Programme (NIHR HTA project number 12/201/09). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health

Background. Low back-related leg pain (LBLP) is clinically diagnosed as referred leg pain or sciatica. Within the spectrum of LBLP there may be unrecognised subgroups of patients. This study aimed to identify and describe clusters of LBLP patients using latent class analysis (LCA). Methods. The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were described and compared to the clinically defined groups of LBLP patients. Results. A five cluster solution was optimal. Cluster one (n=104) had mild leg pain severity, no clinical signs suggestive of sciatica and more anxiety. Cluster two (n=122), three (n=188) and four (n=69) represented mild, moderate and severe sciatica in terms of response to clinical assessment items, pain severity and impact on function. Cluster five (n=126) was more difficult to define based on response to clinical assessment items (below knee pain and possible neural tension) and had a similar severe profile to cluster four in terms of high pain, disability, psychosocial factors, work impact and risk of poor outcome; but had longer duration pain and more comorbidities. Cluster three consistently mirrored the profile of the overall group of patients with a clinical diagnosis of sciatica. Cluster one mirrored the referred leg pain group. Conclusion. This is the first study that used LCA to classify LBLP patients, including sciatica. These clusters could represent more homogenous groups that may require different treatment approaches. Further work will describe the clinical course and longer term outcomes of these clusters. No conflicts of interest. S Stynes is supported by an NIHR/CNO Clinical Doctoral Research Fellowship (CDRF-2010-055). Dr Konstantinou is supported by a HEFCE/NIHR Senior Clinical Lectureship. Professor Hay is a NIHR Senior Investigator

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

Background. Pain with radiation to the leg is a common presentation in back pain patients. Radiating leg pain is either referred pain or radicular, commonly described as sciatica. Clinically distinguishing between these types of leg pain is recognized as difficult but important for management purposes. The aim of this study was to investigate inter-therapist agreement when diagnosing referred or radicular pain. Methods. Thirty-six primary care consulters with low back-related leg pain were assessed and diagnosed as referred or radicular leg pain by one of six trained experienced musculoskeletal physiotherapists. Assessments were videoed, excluding any diagnosis discourse, and viewed by a second physiotherapist who made an independent diagnosis. Therapists rated their confidence with diagnosis and reasons for their decision. Data was summarized using percentage agreements and kappa (K) coefficients with two sided 95% confidence intervals (CI). Results. The therapists assessing and therapists watching the video both diagnosed radicular pain in 25 of the 36 patients. Agreement was 72% with fair inter-rater reliability (K = 0.35, 95% CI 0.07, 0.63, p<0.05). Mean confidence in diagnosis was 87% for radicular pain and 83% for referred pain. In the subgroup of patients where therapists' confidence in diagnosis was ≥ 80% (n=28), agreement was 86% with substantial reliability (K = 0.65, 95% CI 0.37, 0.93 p<0.001). Conclusion. Reliability was fair among therapists when diagnosing back-related leg pain. This concurs with current opinion that differentiating between types of back-related leg pain can be difficult. However, when confidence in clinical diagnosis is high, levels of agreement and reliability indices improve substantially

Purpose. To evaluate the competencies of spinal extended scope physiotherapists (ESP) following the introduction of requesting rights for magnetic resonance imaging (MRI) one year later. Methods. From September 2009 to August 2010 each MRI scan requested by the 2 spinal ESPs within the orthopaedic clinic was recorded along with their clinical diagnosis to ascertain why the scan was requested. This was indicated on a four point scale of likelihood of pathology which had been introduced to give evidence for MRI requesting rights. This was then audited to determine the total number of scans requested along with the accuracy or justification of the request. Results. 589 patients in total were seen in the time period by 2 spinal ESPs and of these 193 (33%) were referred for MRI scans. The breakdown of figures for the diagnosis showed that 18% of scans were for possible serious spinal pathology (SSP). 66% for lumbar spine/radiculopathy, 11% for cervical spine/radiculopathy, 2% thoracic and 3% were consideration for surgery eg. possible fusion. The accuracy of diagnosis, as measured by the clinical impression within a 4 point scoring system and its concordance with the MRI result indicated that for the lumbar spine accuracy rate was 71%, for the cervical spine 62.5%, Myelopathy 50%, SSP 16%. Conclusion. It is important that the requesting of MRIs by members of the orthopaedic team other than spinal consultants can be audited to demonstrate competency of clinical assessment and examination within the team. This results in cost effectiveness in requesting imaging appropriately according to patient needs rather than blanket referrals for scans which can be unnecessary. Data will continue to be collected and a report produced on an annual basis to ensure continuing competency

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making. Retrospective cohort analysis. 120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88). We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making. Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment. Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected

A clinical diagnosis of Myofascial Pain Syndrome (MPS) requires manual palpation for the identification of at least one clinically relevant trigger point (TP). However, few comparable, high quality studies exist regarding the robustness of TP examination. Our aim was to determine the inter-observer agreement of TP examination among four examiners and whether reproducibility is influenced by examiner clinical experience. Two experienced and two inexperienced clinicians each performed a standardized palpation of the upper Trapezius musculature. Each observer was asked to judge the presents/absence of clinically relevant TP(s) using clinician global assessment (GA). A random case mix of 81 female participants was examined, 14 being asymptomatic and the remainder suffering from neck/shoulder pain. Examiners received psychomotor training and video analysis feedback provided prior to and during the study in order to improve protocol standardization. Kappa co-efficients were calculated for all possible examiner pairings. Good agreement was noted between the experienced pairing (κ= 0.63). Moderate levels of agreement were observed among the two mixed pairings (κ=0.35 and 0.47 respectively). However, poor agreement was observed for the inexperienced pairing (κ=0.22). Inter-observer agreement was not stable with the experienced pairing in particular, exhibiting a sharp decline in agreement during the latter portion of the study. Identification of clinically relevant TPs of the upper Trapezius musculature is a reproducible procedure when performed by two experienced clinicians. However, an experienced-inexperienced observer pairing can yield acceptable levels of agreement. A protracted period of data collection may be detrimental to inter-observer agreement

Introduction. Marfan syndrome (MFS) is a common connective tissue disorder affecting one in 3300 people worldwide, and is caused by unique mutations in the 65 exon gene for fibrillin-1—an essential microfibril component of ligaments, tendons, and muscle. A recently discovered feature in the Marfan mouse model is increased concentrations of transforming growth factor β, resulting in overgrowth. 70% of patients with MFS have scoliosis of some degree. Can lessons be learned from MFS aetiology and treatment that apply to idiopathic adolescent scoliosis? We aimed to establish whether there is a relationship between the type and location of mutation, and the presence and degree of severity of scoliosis, in patients with MFS. Methods. Of 181 consecutive patients with MFS with known causative fibrillin-1 mutations, 93 were male (51%) and 88 female (49%). 28 (15%; ten males, 18 females) of the total group had moderate to severe scoliosis, including two females and two males who had corrective surgery. Of the 16 patients with severe scoliosis (three males, 13 females), FBN1 mutations clustered in the latter half of the gene in exons 33–63. Of these 16 mutations, ten were severe (seven stop codons, three splice site mutations); the others were point mutations, three involving added cysteine and three substituted cysteine, in calcium-binding EGF-like regions. Height A rapid adolescent growth spurt to excessive height is a documented clinical feature in MFS. The age of clinical diagnosis as an indication of severity was on average 11·3 years (range 2 days to 36 years), and ten patients were diagnosed before the age of 12 years. Conclusions. Genotype-phenotype correlation for patients with MFS with moderate to severe scoliosis shows the trend/association of severe mutations in 25%, with 50% of the total in the latter half of the gene (exons 33–63) with stop codons and splice site mutations. Cysteine substitutions in calcium binding EGF-like regions occurred in a further 25% of mutations. Disruption of spinal support together with rapid excessive early pubertal growth presents a human model for production of scoliosis, and a rationale for attempted preventive irbesartan therapy in Marfan mouse models and human patients. The 21-centre national AIMS Trial of irbesartan in MFS commences in January, 2011, and skeletal measurements will be of interest

Aims

The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD).

Back pain affects 70% of the population in developed countries and accounts for 13% of sickness absence in the United Kingdom. 1. The clinical presentation might be taken less seriously and could result in significant morbidity and mortality. We did a retrospective observational study of patients admitted on an “acute” basis in our unit. Our aim was to identify the epidemiological proportion of patients who had significant life changing spinal conditions. 239 patients were admitted between January 2004 to December 2008 who presented with non traumatic back pain and related symptoms. The group of patients who had osteoporotic compression fractures were excluded. The mean age was 53.6 and patients were predominantly females. Disc protrusions and degenerative conditions accounted for majority of the patients. Cauda Equina Syndrome (CES) and Cord compressions together contributed to 7.9% and 8.7% respectively. The mean length of stay was 10.4 days and the average wait for MRI scan was 2.4 days. Among the patients who present with back pain in the primary care setting, 3% have disc protrusions and 1% neoplastic lesions. 1. But the epidemiological distribution among the back pain admissions in the hospital setting is not very clear. Medico legal costs especially with CES are quite substantial. 2. and hence it would be useful to know the volume of patients with potential disabling lesions. Our study reveals that a significant proportion of patients who had to be admitted with back pain and especially those having red flag signs have serious spinal pathologies. Early diagnosis and timely intervention could prevent unwarranted morbidity and mortality

Aims

This study aimed to determine the relationship between pedicle-lengthening distance and bulge-canal volume ratio in cases of lumbar spinal stenosis, to provide a theoretical basis for the extent of lengthening in pedicle-lengthening osteotomies.

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

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded.

In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.