This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes. A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group. In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes. Cite this article: Bone Joint J 2013;95-B:81–9

Methods. In this study of patients who underwent internal fixation without fusion for a burst thoracolumbar or lumbar fracture, we compared the serial changes in the injured disc height (DH), and the fractured vertebral body height (VBH) and kyphotic angle between patients in whom the implants were removed and those in whom they were not. Radiological parameters such as injured DH, fractured VBH and kyphotic angle were measured. Functional outcomes were evaluated using the Greenough low back outcome scale and a VAS scale for pain. Results. Between June 1996 and May 2012, 69 patients were analysed retrospectively; 47 were included in the implant removal group and 22 in the implant retention group. After a mean follow-up of 66 months (48 to 107), eight patients (36.3%) in the implant retention group had screw breakage. There was no screw breakage in the implant removal group. All radiological and functional outcomes were similar between these two groups. Although solid union of the fractured vertebrae was achieved, the kyphotic angle and the anterior third of the injured DH changed significantly with time (p < 0.05). . Discussion. The radiological and functional outcomes of both implant removal and retention were similar. Although screw breakage may occur, the implants may not need to be removed. Take home message: Implant removal may not be needed for patients with burst fractures of the thoracolumbar and lumbar spine after fixation without fusion. However, information should be provided beforehand regarding the possibility of screw breakage. Cite this article: Bone Joint J 2016;98-B:109–16

Aims. To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine. Methods. A total of 63 consecutive patients with a degenerative spondylolisthesis and preoperative prone traction radiographs obtained since 2010 were studied. Slip distance, slip angle, disc height, segmental lordosis, and global lordosis (L1 to S1) were measured on preoperative lateral standing radiographs, flexion-extension lateral radiographs, prone traction lateral radiographs, and postoperative lateral standing radiographs. Patients were divided into two groups: posterolateral fusion or posterolateral fusion with interbody fusion. Results. The mean changes in segmental lordosis and global lordosis were 7.1° (SD 6.7°) and 2.9° (SD 9.9°) respectively for the interbody fusion group, and 0.8° (SD 5.1°) and -0.4° (SD 10.1°) respectively for the posterolateral fusion-only group. Segmental lordosis (ρ = 0.794, p < 0.001) corrected by interbody fusion correlated best with prone traction radiographs. Global lumbar lordosis (ρ = 0.788, p < 0.001) correlated best with the interbody fusion group and preoperative lateral standing radiographs. The least difference in slip distance (-0.3 mm (SD 1.7 mm), p < 0.001), slip angle (0.9° (SD 5.2°), p < 0.001), and disc height (0.02 mm (SD 2.4 mm), p < 0.001) was seen between prone traction and postoperative radiographs. Regression analyses suggested that prone traction parameters best predicted correction of slip distance (Corrected Akaike’s Information Criterion (AICc) = 37.336) and disc height (AICc = 58.096), while correction of slip angle (AICc = 26.453) was best predicted by extension radiographs. Receiver operating characteristic (ROC) cut-off showed, with 68.3% sensitivity and 64.5% specificity, that to achieve a 3.0° increase in segmental lordotic angle, patients with a prone traction disc height of 8.5 mm needed an interbody fusion. Conclusion. Prone traction radiographs best predict the slip distance and disc height correction achieved by interbody fusion for lumbar degenerative spondylolisthesis. To achieve this maximum correction, interbody fusion should be undertaken if a disc height of more than 8.5 mm is attained on preoperative prone traction radiographs. Level of Evidence: Level II Prognostic Study. Cite this article: Bone Joint J 2020;102-B(8):1062–1071

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. Methods. First, we validated the accuracy and repeatability of a custom-made mechanical loading equipment set-up. Eight lumbar specimens underwent CT scanning in flexion, neural, and extension positions by using the equipment set-up. The changes in the disc height and distance between adjacent two pedicle screw entry points (DASEP) of the posterior approach at different lumbar levels (L3/4, L4/5 and L5/S1) were examined on three-dimensional lumbar models, which were reconstructed from the CT images. Results. All the vertebral motion segments (L3/4, L4/5 and L5/S1) had greater changes in disc height and DASEP from neutral to flexion than from neutral to extension. The change in anterior disc height gradually increased from upper to lower levels, from neutral to flexion. The changes in anterior and posterior disc heights were similar at the L4/5 level from neutral to extension, but the changes in anterior disc height were significantly greater than those in posterior disc height at the L3/4 and L5/S1 levels, from neutral to extension. Conclusions. The lumbar motion segment showed level-specific changes in disc height and DASEP. The data may be helpful in understanding the physiologic dynamic characteristics of the lumbar spine and in optimising the parameters of lumbar surgical instruments. Cite this article: M. Fu, Q. Ye, C. Jiang, L. Qian, D. Xu, Y. Wang, P. Sun, J. Ouyang. The segment-dependent changes in lumbar intervertebral space height during flexion-extension motion. Bone Joint Res 2017;6:245–252. DOI: 10.1302/2046-3758.64.BJR-2016-0245.R1

Background. The association between lumbar intervertebral disc degeneration (LDD) and low back pain (LBP) is modest. We have recently shown that genetic propensity to pain is an effect modifier of the LDD-LBP relationship when LDD is defined as a summary score of LDD (LSUM), suggesting the association may be driven by individuals with the greatest genetic predisposition to pain. This study examined the association between individual spine magnetic resonance imaging (MRI)-determined LDD features and LBP in subgroups defined by genetic predisposition to pain. Method. We developed a polygenic risk score (PRS) for “genetic propensity to pain” defined as the number of non-back pain locations (head, face, neck/shoulder, stomach/abdomen, hip, and knee) with duration ≥3 months in 377,538 UK Biobank participants of European ancestry. This PRS was used to stratify TwinsUK MRI samples (n=645) into four strata of genetic propensity to pain. We examined the association between LBP and MRI features of lumbar disc height, disc signal intensity, disc bulge, and osteophytes with adjustments for age, sex, PRS strata, interaction terms for each MRI feature x PRS strata, and twin status. Results. We found significant effect modification of the LDD-LBP relationship by genetic propensity to pain for the lumbar MRI features of disc height (p=0.03 for the interaction term with highest quartile of genetically-predicted propensity to pain) and disc signal intensity (p=0.001), but not for disc bulge and osteophytes. Conclusion. Genetic propensity to pain modifies the association between individual LDD features and LBP and should be considered in LBP clinical studies. Conflicts of interest. No conflicts of interest. Sources of funding. No funding obtained. Acknowledgement. UKBB data were obtained under the project #18219. This paper is submitted to the Spine journal and is under review

Background. We have previously reported an injectable hydrogel (NPgel), which could deliver patients own stem cells, via small bore needles, decreasing damage to the annulus fibrosus. NPgel drives differentiation to NP cells and can inhibit the degenerate niche. However, clinical success of NPgel is dependent on the capacity to inject NPgel into naturally degenerate human discs, restore mechanical function to the IVD, prevent extrusion during loading and induce regeneration. This study assessed injectability of NPgel into human IVD, influence on mechanical properties, regeneration ability in an ex vivo culture system and retention under failure testing. Methodology. Cadaveric human discs were used to calculate disc height and to determine Youngs Modulus during simulated walking pre and post injection of NPgel, extrusion testing performed. Whole human IVDs were injected with NPgel +/− human BMPCs and maintained in culture under physiological loading regime for 4 weeks. Pre and post culture MRI imaging and in line biomechanical characteristics determined. Histology and immunochemistry performed for anabolic and catabolic factors. Results. NPgel injection significantly increased disc height and Youngs modulus with no extrusion observed during failure testing. T1ρ intensity was increased during culture in those injected with NPgel +/− cells compared to non-injected discs, and biomechanical restoration. Histological analysis has demonstrated excellent tissue attachment to the injected gel, and cellular migration into acellular gel systems. With increased matrix production and decreased catabolic factor expression. Conclusion. These results provide essential proof of concept data supporting the use of NPgel as an injectable therapy for disc regeneration. Conflict of interest: C Le Maitre & C Sammon are inventors on the hydrogel discussed. Funding: This work was funded by MRC and Versus Arthritis

Background. Dynamic measurement of continuous intervertebral motion in low back pain (LBP) research in-vivo is developing. Lumbar motion parameters with the features of biomarkers are emerging and show promise for advancing understanding of personalised biometrics of LBP. However, measurement of changes over time inevitably involve error, due to subjects' natural variation and/or variation in the measurement process. Thus, intra-subject repeatability of parameters to measure changes over time should be established. Methods. Seven lumbar spine motion parameters, measured using quantitative fluoroscopy (QF), were assessed for intra-subject repeatability: Intervertebral range-of-motion (IV-RoM), laxity, motion sharing inequality (MSI), motion sharing variability (MSV), flexion translation and flexion disc height. Intra-subject reliability (ICC) and minimal detectable change (MDC95) of baseline and 6-week follow-up measurements were obtained for 109 healthy volunteers (54 coronal and 55 sagittal). Results. Reliability was substantial to excellent for repeated measurements of IV-RoM, laxity, flexion translation and disc height during recumbent passive motion (ICC:0.69–0.95) and during active weight-bearing motion (ICC:0.64–0.92). MSI was moderate to excellent across both positions (ICC:0.43–0.91). The reliability of MSV was generally poorer for both positions (0.14–0.65). For all parameters, measurement error exceeded 42%. Conclusion. Recumbent IV-RoM, laxity and disc height demonstrated the best repeatability at 6-weeks suggesting they may be better outcome moderators in clinical studies than other variables. However measurement errors for all parameters were higher than the minimal changes of interest. These results are limited to healthy controls and should be regarded as reference values. Similar studies in CNSLBP patients are required. No conflicts of interest. Sources of Funding: Dr Rebecca Hemming received a Seedcorn Bursary from the Cardiff Institute of Tissue Engineering and Repair (CITER) and Professor Alan Breen received a project grant from the European Chiropractors Union Research Fund (ECURF)

Study purpose and background. Kinematic variables have been identified as potential biomarkers for low back pain patients; however, an in-depth comparison between chronic (n=22), acute (n=15), and healthy controls (n=136) has not been done. This retrospective data analysis compared intervertebral lumbar motion parameters, angular range of motion, translation, maximum disc height, motion share inequality (MSI) and variability (MSV), and laxity, between these groups. Methods and results. Kinematic parameters were determined using video tracking techniques utilising quantitative fluoroscopy (QF), during both weight-bearing and recumbent controlled sagittal bending tasks. Data was analysed for normality, and appropriate statistical tests were applied to determine differences between groups. There were no significant differences between the groups for age, height, weight and sex. Whilst few differences were found between acute and healthy groups, differences were shown between both chronic and healthy, and acute and chronic groups for all six parameters. Of particular note were examples of differences in the motion share parameters between the acute and chronic populations, with an increased MSI in the chronic group during recumbent flexion, and MSV during recumbent extension, and inversely an increase in MSV in the acute group during weight-bearing flexion. Conclusion. Analysis of intervertebral lumbar motion provides valuable insights into kinematic differences between chronic, acute, and healthy control populations. These findings suggest that there is variation between the groups which is knowledge that may benefit management strategies. Further exploration of the time varying data is warranted to explore how such differences may relate to the motion share inequalities and variability shown. Conflicts of Interest. No conflicts of interest. Sources of Funding. No funding obtained

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis. Thirty two Levels in Twenty Six patients were followed up with standardised radiographs after insertion of Wallis Ligaments for Foraminal Stenosis. Wallis ligaments as a top-off or those with prolapsed discs were not included. The Radiological parameters compared were Anterior and Posterior Disc height, Foraminal height and width, The inter-vertebral angle (IVA), Lumbar lordosis and Scoliosis if any. The presence of slips and their progression post-op was noted, as was bony lysis if any. There were ten males with thirteen levels and sixteen females with nineteen levels in the study. Eighteen levels (56.25%) were L4/L5, ten (31.25%) were L5/S1 and 4 (12.5%)were L3/L4. The average age in the series was 59.6 years (Range 37 – 89 yrs). Average follow up was 9.5 months (Range 2 to 36). The Average increase in Anterior disc height was 1.89 mm (+/−1.39), the posterior disc height increased by an average 1.09 mm (+/−1.14). Foraminal height increased by an average 3.85 mm (+/− 2.72), while foraminal width increased by 2.14 mm (+/− 1.38). The IVA increased in 16 and reduced in 15 patients, with no change in 1. Lumbar Lordosis increased in 23 patients, with an average value of 2.3°. No patient exhibited progression in scoliosis and no lysis could be identified. There were three Grade I slips pre-op; none progressed. Foraminal dimensions and Disc height were consistently improved after Wallis insertion. Changes in IVA and Lumbar lordosis were however variable. A longer follow up is suggested to look for sustained improvement and the presence of lysis

Background and purpose of study:. Modic change (MC) describes vertebral endplate and bone marrow lesions visible on MRI. MC has been associated with disc degeneration (DD). Independent association of MC with low back pain (LBP) is unclear. The objectives of this study were to assess the relationship between MC and severe, disabling LBP; prevalence and features of DD and incident MC during 10-year follow-up. Methods and results:. Unselected TwinsUK volunteers were recruited to MRI and nurse interview in 1996–2000 (n=823): a subset attended for follow-up a decade later (n=429). T2-weighted lumbar MR scans were coded blindly for MC, DD (loss of disc height and signal intensity, disc bulge and anterior osteophytes) and Schmorl's nodes (SN). Mean baseline age = 54.0 (32–70) years with 96% female. Prevalence of MC was 32.2% (baseline) and 48.7% (follow-up). Univariable analyses showed subjects having MC were older (p<0.001) and more overweight (p=0.026). At both timepoints subjects reporting severe LBP episodes demonstrated more MC (both p<0.001) than those without LBP. In multivariable analyses, MC remained significantly associated with episodes of severe, disabling LBP (OR 1.58; 95% CI 1.04–2.41) even after adjustment for age, BMI, DD and SN. Loss of disc height and disc signal intensity were independently associated with prevalent MC at baseline, and disc height and disc bulge with incident MC during follow-up. Conclusions:. MC is associated with all disc features of DD but not anterior osteophytes. MC is an independent risk factor for episodes of severe and disabling LBP in middle-aged women

Posterior lumbar interbody fusion (PLIF) is indicated for many patients with pain and/or instability of the lumbar spine. We performed 36 PLIF procedures using the patient’s lumbar spinous process and laminae, which were inserted as a bone graft between two vertebral bodies without using a cage. The mean lumbar lordosis and mean disc height to vertebral body ratio were restored and preserved after surgery. There were no serious complications. These results suggest that this procedure is safe and effective

Aims. The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability. Patients and Methods. A total of 304 consecutive patients with single-level lumbar DS with concomitant stenosis underwent microendoscopic laminotomy without fusion between January 2004 and December 2010. Patients were divided into two groups, those with and without advanced DS based on the degree of spondylolisthesis and dynamic instability. A total of 242 patients met the inclusion criteria. There were 101 men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome was assessed using the Japanese Orthopaedic Association and Roland Morris Disability Questionnaire scores, a visual analogue score for pain and the Short Form Health-36 score. The radiographic outcome was assessed by measuring the slip and the disc height. The clinical and radiographic parameters were evaluated at a mean follow-up of 4.6 years (3 to 7.5). Results. There were no significant differences in the preoperative measurements between the group and no significant differences between the clinical parameters at the final follow-up. The mean percentage slip was 17.1% preoperatively and 17.7% at the final follow-up (p = 0.35). Progressive instability was noted in 13 patients (8.2%) with DS and 6 patients (7.0%) with advanced DS, respectively (p = 0.81). There was radiological evidence of restabilization of the spine in 30 patients (35%) with preoperative instability. The success rate of microendoscopic laminotomy was good/excellent in 166 (69%), fair in 49 (20%) and poor in 27 patients (11%) in both groups. Conclusion. Microendoscopic laminotomy is an effective form of surgical treatment for patients with DS and stenosis. Preservation of the stabilizing structures using this technique prevents postoperative instability. Cite this article: Bone Joint J 2018;100-B:499–506

Auckland City Hospital, Auckland, New Zealand. To show that the spinous processes (SPs) increase in size with age. To investigate the incidence of SP abutment, relationship to disc degeneration and age related kyphosis. Describe patterns of SP neoarticulation in relation to back pain and intersegmental axial rotation and deformity. We reviewed 200 Abdominal CTs, CT myelograms and 100 standing x-rays (age 18-90 years). We measured SP size, interspinous gap, patterns of neoarticulation, disc height, lumbar lordosis and axial rotation. We compared symptomatic and asymptomatic groups. A 30-50% increase in SP size coupled combined with a loss of disc height leads to increasing rates of SP abutment after the age of 35 years. 30% of people over the age of 60 years have SP abutment. There is a 15 degree increase in standing lumbar kyphosis with age. Four patterns of SP neoarticulation are seen. Degenerative changes in the SP articulation increase by more than 80% in a symptomatic cohort. Oblique SP articulation is 2.5 times more likely in symptomatic individuals and associated with a rotational intersegmental deformity. Ageing is accompanied by SP enlargement and abutment, contributing to a loss of lumbar lordosis. Patterns of neoarticulation and degeneration appear associated with back pain and rotational deformity

To assess the clinical and radiological outcome of single and multiple level Anterior Cervical Disc Replacement (ACDR) using Peek-on-peek system. We present the largest series of POPCDR at a single centre. Thirty-one patients with radiculopathy and/or myelopathy caused by disc generation who did not respond to conservative treatments were included. Pain and function were evaluated by VAS (Visual Analogue Score) for neck (VAS-NP) and arm pain (VAS-AP). Neck disability index (NDI) and SF-36 questionnaires were completed. Disc height and segmental angular correction (SAC) were measured on radiographs pre- and postoperatively. Seven patients had one-level, fifteen had two-level, seven had three-level and two had four-level ACDR. Sixty-six discs were replaced. Average follow-up was six months. Mean VAS-NP improved from 7.27 to 3.93 and VAS-AP from 7.27 to 3.4. Mean SF-36 improved from 32.21 to 40.22. There was functional improvement for NDI in all patients. There was an improvement in SAC from 5.4. ° . to 8.0. ° . for one-level, 3.1. °. to 7.5. °. for two level, 8.4. °. to 9.4. °. for three-level and 5.8. °. to 26.7. °. for four-level ACDR. Post-operative anterior disc height increased by 152% for lower and 55% for higher levels. Similar improvements were noted for posterior disc heights. Early results show that POPCDR is safe and effective for treatment of symptomatic cervical disc disease. The clinical and radiological outcomes are similar to other types of ACDR reported in literature. POPCDR also allows safe use of MRI during follow-up with fewer artifacts giving it an edge over other systems

Purpose of study and background. Low back pain affects 80% of the population at some point in their lives with 40% of cases attributed to intervertebral disc (IVD) degeneration. A number of potential regenerative approaches are under investigation worldwide, however their translation to clinic is currently hampered by an appropriate model for testing prior to clinical trials. Therefore, a more representative large animal model for IVD degeneration is needed to mimic human degeneration. Here we investigate a caprine IVD degeneration model in a loaded disc culture system which can mimic the native loading environment of the disc. Methods and Results. Goat discs were excised and cultured in a bioreactor under diurnal, simulated-physiological loading (SPL) conditions, following 3 days pre load, IVDs were degenerated enzymatically for 2hrs and subsequently loaded for 10 days under physiological loading. A PBS injected group was used as controls. Disc deformation was continuously monitored and changes in disc height recovery quantified using stretched-exponential fitting. Histological staining was performed on caprine discs to assess extracellular matrix production and immunohistochemistry performed to determine expression of catabolic protein expression. The injection of collagenase and cABC induced mechanical behavior akin to that seen in human degeneration. A decrease in collagens and glycosaminoglycans (GAGs) was seen in enzyme injected discs, which was accompanied by increased cellular expression for degradative enzymes and catabolic cytokines. Conclusion. This model provides a reproducible model of IVD degeneration which mimics human degeneration. This model allows the testing of biomaterials and other potential treatments of IVD degeneration on a scale more representative of the human disc. There are no conflicts of interest. Funded by MRC and Versus Arthritis

Introduction. Injectable hydrogels via minimally invasive surgery reduce the risk of infection, scar formation and the cost of treatment. Degradation of the intervertebral disc (IVD) currently has no preventative treatment. An injectable hydrogel material could restore disc height, reinforce local mechanical properties, and promote tissue regeneration. We present a hydrogel material Laponite. ®. associated poly(N-isopropylacrylamide)-co-poly(dimethylacrylamide) (NPGel). Understanding how the components of this hydrogel system influence material properties, is crucial for tailoring treatment strategies for the IVD and other tissues. Methods & Results. The effect of hydrogel wt./wt., clay and co-monomer percentages were assessed using a box-Behnken design. Rheometry, SEM, FTIR and swelling was used to measure changes in material properties in simulated physiological conditions. Rheometry revealed gelation temperature of hydrogel materials could be modified with dimethyl-acrylamide co-monomer; however, final maximum mechanical properties remained unaffected. Increasing the weight % and clay % increased resultant mechanical properties from ∼500–2500 G' (Pa), increased viscosity, but retained the ability to flow through a 26G needle at 39°C. Discussion & Conclusions. By increasing the weight and clay percentage of the material we can attain greater mechanical properties, this could be beneficial for orthopaedic or even dental applications. By modifying the co-monomer percentage, we can control gelation temperature important for ensuring the material is fully set at 37°C, this could also be utilised to locally deliver drugs from the implanted material. Our current work is focused on comparing our NPGel material formulation with human IVD tissue. Acknowledgements. We would like to thank Arthritis Research UK grant number 21497 for supporting this research. No conflicts of interest. Sources of Funding: Funded by Arthritis Research UK grant number 21497

Objectives. A single degenerate intervertebral disc is suggested to promote rapid degeneration in its adjacent discs. We validated this hypothesis using discordant co-twin case-control design. Methods. 185 pairs of twins were selected from the TwinsUK database having cervical MRI scans at baseline and at follow-up, after 10 years. Isolated disc degeneration (IDD) was diagnosed in subjects having severe loss in disc height (graded 3/3) in a single disc, whilst discs immediately adjacent manifested little or no degeneration (graded 0 or 1). The controls' ‘adjacent discs’ were considered at the same levels as their affected co-twins. Results. Eight twin pairs fulfilled case/control criteria. At follow-up, no significant difference in adjacent disc degeneration between IDD cases and controls remained (p=0.69). Conclusions. Using a highly matched case-control design we did not find evidence that lone IDD has an adverse effect on the natural rate of adjacent disc degeneration in the cervical spine. No conflicts of interest. Acknowledgements. This study was supported by a grant from Globus Inc. Arthritis Research UK supported the imaging costs. TwinsUK. The study was funded by the Wellcome Trust; European Community's Seventh Framework Programme (FP7/2007–2013). The study also receives support from the National Institute for Health Research (NIHR)- funded BioResource, Clinical Research Facility and Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust in partnership with King's College London

Purpose and Background:. Clinical interpretations of Degenerative Lumbar Disc Disease are not described in the literature. The purpose of this study was to establish a consensus of expert clinical opinion in order to fuel further research. Methods:. A reliable and valid electronic survey was designed to include theoretical constructs relating to training and education, general knowledge, assessment and management practices. Clinicians from the Society of Back Pain Research U.K. were invited to take part. Quantitative data was collated and coded using Bristol on-line survey software, and content analysis was used to systematically code and categorize qualitative data. Results:. Respondents represented a wide range of clinical specialties. The majority graduated in the U.K. (87%), were clinically active and had greater than 9 years postgraduate clinical experience (84%). MRI (36%) and physical assessment (21%) were cited as the most important clinical assessment tools. Reduction in disc height (92%) and disc dehydration (90%) were reported as the most important variables with respect to DLDD diagnosis. The most effective treatment approaches varied from education and reassurance, pain management, cognitive behavioural approaches to core stability training and group activity. Health professionals viewed the future of care advancement in terms of improvements in patient communication (35%) and education (38%). Treatment stratification (24%) and advancing evidence based management practices through research were also regarded as essential (27%). Conclusion:. Spinal clinical experts have clear views on DLDD assessment. In terms of management the results are varied suggesting inconsistency and uncertainty

Lumbar spine foraminal stenosis has previously been defined by the foraminal and posterior disc height. We performed a study to determine whether residual clinically significant foraminal stenosis correlates with foraminal dimensions and peri-neural fat signal loss in a group of patients with leg pain undergoing surgery for lateral recess stenosis. We retrospectively studied the pre-operative para-sagittal MRI slices of 57 patients undergoing lumbar decompression and measured pre- and post-operative VAS as a primary outcome measure to evaluate surgical success. We performed a linear regression analysis comparing change in VAS score, 1 year VAS and percentage change in VAS with foraminal height and width and found no significant correlation (R. 2. <0.2 for all correlations). We identified a sub-group of 16 patients with absent perineural foraminal fat signal with a significantly increased probability of post-operative VAS>2 compared to patients with present fat signal (p=0.0001) who all had foraminal height <10mm. In conclusion, we were unable to define dimensional foraminal parameters for clinically significant foraminal stenosis on para-sagittal MRI. Obliteration of perineural fat was associated with worse outcome and post-operative leg pain. The aetiology of foraminal stenosis is multi-factorial and more detailed imaging of the foramen is required. We recommend that coronal and fine para-sagittal MRI slices are analysed to evaluate patients with central and lateral recess stenosis for co-existing foraminal stenosis

Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain. We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5. Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons. Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing