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

Background. Information about low back pain (LBP) and help to support patients' self-management are recommended in the majority of guidelines for LBP management. However, the delivery of patient information and advice can be time consuming, and with short available consultation times for general practitioners (GPs), new methods to support the delivery of sufficient patient information is called for. Purpose. To identify general practitioners' perspectives on recommending online information to patients with LBP. Methods. Danish GPs varying in age and professional interests were recruited to interviewing in their practices (their working environment). The interviews were based on a semi-structured interview guide, based on a value-led method, and inspired by think aloud methods,. Results. Eight 60-Minutes interviews were conducted. For GPs to recommend online LBP information, it is essential to target the information to their patients. GPs expressed the possible advantages by involving both healthcare professionals and patients in the development of the online information material by aligning the content with the face-to-face delivered information. Furthermore, the content should be guideline concordant. However, GPs expressed that some patients had problems with accessing and understanding health-related LBP information. Conclusion. When developing online information, the content should be supported by evidence and it is important to involve patients' and GPs' preferences in the design process. Consequently, including the elements in evidence-based medicine. However, GPs do not consider online information material to be suited to all. No conflicts of interest. Sources of funding: Funded by ARs' Honour in Medical Research from Magda and Svend Aage Friederichs Memorial Fund and the Novo Nordic Foundation

Introduction

Purpose of study. A recent audit in our institution showed that 40% of Lumbar spine X-rays ordered by General Practitioners were outside the Royal College of Radiology guidelines. Little in 1998 had commented that GPs requested Lumber Spine X-rays for psychosocial reasons. Methods. An online survey was conducted on . www.surveymonkey.com. among the local GPs to determine their practice and preferences in investigating low back pain. The 5 questions in the survey were “rating scale questions” on a scale of 1 and 10, where 1 = DISAgree and 10 = Agree. A request to participate in the survey was sent to all the local General Practitioners by e-mail. Results. 36 General Practitioners participated in the survey. Participants agreed that if there were no red flags and no significant neurological deficit they were satisfied in not requesting further investigations (6.03/10). They did not feel the need to order investigation just to reassure an anxious patient (5.31). In day to day practice they however were forced to request X-rays (6.72) though they preferred to request MRI scans (7.55). They also felt frustrated that MRI scans could not be directly ordered by GPs (6.69). Conclusion. This limited study demonstrates that General Practitioners “Do not investigate back pain just to reassure the patient but are frustrated that they are not able to directly request MRI scans for their patients. Increased efforts to educate the public and health professionals that a negative X-ray result of the lumbar spine is not reassuring should be matched by easy access to MRI scans

Purpose of study. NICE recommends 8-9 sessions of non operative therapy for back pain that has lasted for 6 weeks but less than 12 months. NICE recommended exercises, manual therapy, acupuncture and suggested that Lumbar supports, TENS, Ultrasound and Traction should not be offered. Since multiple methods and disciplines were available a survey was conducted among the local General Practitioners to determine what non operative methods they preferred and how it matched with NICE's recommendation. Methods. An online survey was conducted on . www.surveymonkey.com. among the local GPs to determine their practice and preferences in investigating low back pain. The 5 questions in the survey were “rating scale questions” on a scale of 1 and 10, where 1 = DISAgree and 10 = Agree. A request to participate in the survey was sent to all the local General Practitioners by e-mail. Results. 25 General Practitioners participated in the survey. A sample of the scores obtained were as follows. Method of treatment. Mean Score. Mobilisation exercises. 8.20. Specific Core Stability Exercises. 8.13. Physiotherapy. 7.96. Pilates. 7.21. Attending a Gymnasium. 6.32. Medications. 6.20. Yoga. 6.18. TENS (Transcutaneous electrical nerve stimulation). 5.44. Acupuncture. 5.44. Chiropractory. 5.42. Osteopathy. 5.41. Massage. 4.73. Ultrasound. 3.43. Traction. 2.75. Lumbar support. 2.65. Conclusion. This limited study demonstrates that General Practitioners prefer patients to use active modalities of treatment like exercises which require participation of the patient rather than passive methods of treatment like lumbar support and massage. The choices of the GPs are nearly in tune with the recommendations of NICE with some exceptions. TENS (not recommended by NICE) obtained a better score than Acupuncture (recommended by NICE)

Aim. To use Patient Reported Outcome Measures (PROMs) to determine the effectiveness of lumbar spinal surgery at a single UK institution. Methods. Consecutive patients who underwent lumbar spinal surgery (discectomies or decompressions) from 1 January 2011 to 13 March 2013 at a UK District General Hospital were assessed. The procedures were performed or supervised by a senior Consultant Orthopaedic spinal surgeon. All patients completed PROM questionnaires before and three months following surgery. These included Visual Analogue Scores (VAS), SF-12, Oswestry Disability Index (ODI) and Roland Morris Low Back Pain Questionnaire (RMQ). Results. A total of 230 patients had surgery. Of these, 189 (82%) completed both pre- and post-operative questionnaires. All PROMs showed improvement: VAS for constant back pain improved from 4.1 to 2.1 and exacerbations of back pain from 5.8 to 2.4. VAS for constant leg pain improved from 6.3 to 1.7 and for exacerbations of leg pain from 8.2 to 1.8. Mean ODI from 47 to 21; RMQ from13 to 5; and SF12-psychological and physical components increased by 7.2 and 12.4, respectively. Those patients with better psychological health pre-operatively, (high SF-12 score, >60 [n=14]) had a reduction in mean score (decrease of 3.2) post-operatively. However, those with poorer psychological health pre-operatively (low SF-12 score, <30 [n=18]) showed a marked improvement in mean score post-operatively (increase of 18.9). Conclusions. These results show that lumbar spinal surgery is safe and effective at a District General Hospital. Baseline psychological scores may help predict psychological outcomes following surgery. This warrants further prospective evaluation. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Our aim in this prospective radiological study was to determine whether the flexibility rate calculated from radiographs obtained during forced traction under general anaesthesia, was better than that of fulcrum-bending radiographs before corrective surgery in predicting the extent of the available correction in patients with idiopathic scoliosis. We evaluated 33 patients with a Cobb angle > 60° on a standing posteroanterior radiograph, who had been treated by posterior correction. Pre-operative standing fulcrum-bending radiographs and those with forced-traction under general anaesthesia were obtained. Post-operative standing radiographs were taken after surgical correction. The mean forced-traction flexibility rate was 55% (. sd. 11.3) which was significantly higher than the mean fulcrum-bending flexibility rate of 32% (. sd. 16.1) (p < 0.001). We found no correlation between either the forced-traction or fulcrum-bending flexibility rates and the correction rate post-operatively (p = 0.24 and p = 0.44, respectively). Radiographs obtained during forced traction under general anaesthesia were better at predicting the flexibility of the curve than fulcrum-bending radiographs in curves with a Cobb angle > 60° in the standing position and may identify those patients for whom supplementary anterior surgery can be avoided

Background. Improving primary care management of musculoskeletal (MSK) pain is a priority. A pilot cluster RCT tested prognostic stratified care for patients with common MSK pain presentations, including low back pain, in 8 UK general practices (4 stratified care; 4 usual care) with 524 patients. GPs in stratified care practices were asked to use i) the Keele STarT MSK tool for risk-stratification and ii) matched treatment options for patients at low-, medium- and high-risk of persistent pain. A linked qualitative process evaluation explored patients' and GPs' views and experiences of stratified care. Methods. Individual ‘stimulated-recall’ interviews with patients and GPs in the stratified care arm (n=10 patients; 10 GPs), prompted by consultation-recordings. Data were analysed thematically and mapped onto the COM-B behaviour change model; exploring the Opportunity, Capability and Motivation GPs and patients had to engage with stratified care. Results. Patients reported positive views that stratified care enabled a more ‘structured’ consultation. GPs identified difficulties integrating the STarT MSK tool in their consultation timeframe (Opportunity), but found this easier as it became more familiar. Both groups saw the tool as having added-value, but identified ‘cumbersome’ items which made it more difficult to use (Capability). GPs reported the matched treatment options aided their clinical decision-making, identified several that were not available to them (e.g. pain-management clinics) and suggested additional options (e.g. GP-management of psychosocial issues (Motivation). Conclusion. Changes to the STarT MSK tool and matched treatment options, targeting the COM-B model constructs, were identified and have been implemented in the current main trial. Conflicts of interest statement: No conflicts of interest. Sources of funding: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Nadine Foster is a NIHR Senior Investigator and was supported through an NIHR Research Professorship (NIHR-RP-011-015). Trial registration: ISRCTN15366334

Surgery for spinal deformity was previously carried out only in teaching hospitals in the United Kingdom. With increasing numbers of patients especially adults, seeking treatment for spinal deformity, the number of centres offering treatment for spinal deformity is going to have to increase. The deformity part of the Spinal Surgical Service in the District General Hospital in Taunton started in 2005. This paper is an audit of this deformity service. It looks at two key areas – that of patient satisfaction and patient reported outcomes of surgery. Patient satisfaction was assessed by a validated questionnaire that evaluated a patient's perception of consultations, consent, preoperative assessment, operative and post operative experience and follows up visits. Patient reported outcomes were evaluated using the SRS 30 questionnaire. 104 patients were contacted and 95 patients (91%) responded. The overall patient satisfaction rate was 96%, with 87% very pleased with the result of surgery, 80% felt that their body shape had improved considerably, 62% had an increased ability to carry out day to day activities to a much higher level and 78% had significantly decreased pain after surgery. The results of the different domains of the SRS questionnaire also supported this. The authors believe that this audit proves that it is possible to provide a spinal deformity service in a District General Hospital in the United Kingdom safely and effectively with a high degree of patient satisfaction. Audits of this kind are required to compare results of treatment between different centres and establish standards

Purpose. To investigate the association between vertebral endplate signal changes (VESC) and low back pain (LBP). Methods and materials. This prospective observational study included 344 persons (161 men and 183 women) sampled from the Danish general population. All participants had an MRI and filled in questionnaires at the age of 40 and again at the age of 44. The following LBP outcomes were used: “LBP past month,” “LBP past year,” and “non-trivial LBP”. The type and size of VESC at each endplate level were evaluated using a standardized evaluation protocol. Associations between VESC and LBP were investigated using logistic regression analysis. Results. The prevalence of any type or size of VESC increased with 10% from the age of 40 to age 44. The prevalence of LBP was generally constant over the four year period. Overall, there was a positive association between VESC and LBP at age 40, but at age 44 this association was no longer present. However, persons for whom large type 1 changes disappeared over the four year period were more likely NOT to report LBP at the age of 44. Conclusion. Results from this study indicate that the association between VESC and LBP is not as constant as previously thought

Purpose of the study. To take a snapshot opinion of General Practitioner understanding of the prevalence, diagnosis and management of coccydynia. Methodology. We designed a simple 5 question survey to administer to our local GPs. The survey was sent to 107 GP practices in Devon whose details were provided by The Devon Access Referral Team. We received 128 electronic replies. We also submitted the survey to 50 GPs who attended a study day at our institution – and ensured they had not already completed the electronic format of the same work. Thus we received 178 replies which we believe to be a highly representative sample of our local GPs opinion. Results. 53% correctly identified the prevalence of the condition. 42% believed the condition to be associated with an underlying psychological disorder. 58% believed there was no proven treatment for the condition. Less than 18% would consider referring the patient to any secondary care service that dealt with chronic spinal pain (Pain clinic, rheumatology or spinal surgery) even if the symptoms persisted beyond 3 months duration. 73% believed surgery was madness or had a less than 20% chance of relieving symptoms. Conclusion. Coccydynia is a painful condition, causing significant distress for those suffering with the condition. Primary care physicians seem reluctant to recognise the problem as significant and reluctant to refer patients for treatment that may offer significant symptomatic relief. Education about the condition is required

Back pain affects 70% of the population in developed countries and accounts for 13% of sickness absence in the United Kingdom¹. 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 lesions¹. 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 substantial² 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. Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM. Methods. This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery. Results. A total of 2,114 individuals aged 64.6 years (SD 11.9) who underwent surgery from March 2009 to December 2016 were studied. The most optimal cut-off canal diameters for DcSS are: C3 < 12.9 mm, C4 < 11.8 mm, C5 < 11.9 mm, C6 < 12.3 mm, and C7 < 13.3 mm. Overall, 13.0% (262 of 2,019) of the population-based cohort had multilevel DcSS. Multilevel DcSS (odds ratio (OR) 6.12 (95% CI 3.97 to 9.42); p < 0.001) and male sex (OR 4.06 (95% CI 2.55 to 6.45); p < 0.001) were predictors of developing DCM. Conclusion. This is the first MRI-based study for defining DcSS with multilevel canal narrowing. Level-specific cut-off canal diameters for DcSS can be used for early identification of individuals at risk of developing DCM. Individuals with DcSS at ≥ three levels and male sex are recommended for close monitoring or early intervention to avoid traumatic spinal cord injuries from stenosis. Cite this article: Bone Joint J 2024;106-B(11):1333–1341

Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

Background. Disability is an important multifaceted construct. Identifying sources of disability could help optimise patient care. The aim of this study was to test an approach that not only estimates severity of disability, but also identifies the source(s) of this disability. Methods. An online survey was used to collect data from a convenience sample, recruited via email and social media invitations. Two generic measures of disability, the 8-item Universal Disability Index (UDI8) and Groningen Activity Restriction Scale (GARS) were used to estimate the prevalence and severity of disability in this sample. Non-zero UDI8 item responses generated conditional sub-questions, in which participants could attribute their activity limitations to one or more sources (pain, fatigue, worry, mood, and other). This allowed for a decomposition of UDI8 scores into source components. Results. 403 participants enrolled; 334 completed all UDI8 and GARS items. Of these, 85.3% (285/334) reported at least one restricted activity via the UDI8, while 43.4% (145/334) reported some reduced independence via the GARS. Disability severity increased with age until approximately 40 years, after which it decreased gradually. Pain component scores were high in all individuals with higher and lower disability severity, whereas fatigue component scores were highest in individuals reporting higher disability severity. Worry, mood, and other component scores were not high at any level of disability severity. Conclusions. This approach should be used to identify the prevalence, severity and sources of disability in the general population and in specific patient groups. Conflicts of interest. No conflicts of interest. Sources of funding. No funding obtained

Background. Disability is an important multifaceted construct. The aim of this study was to develop and evaluate a brief, generic self-reported disability questionnaire: the Universal Disability Index (UDI). Methods. Convenience sampling was used to collect general population data via an online survey. Data were randomly divided into training and validation subsets. The dimensionality and structure of eight UDI questionnaire items were evaluated using exploratory factor analysis (EFA, training subset) followed by confirmatory factor analysis (CFA, validation subset). To assess concurrent validity, the UDI summed score from the full dataset was compared to the Groningen Activity Restriction Scale (GARS) and the Graded Chronic Pain Scale (GCPS) disability scores. Internal consistency was also assessed. Results. 403 participants enrolled; 364 completed at least one UDI item. Three single-factor versions of the UDI were assessed (8-item, 7-item, and 6-item). All versions performed well during EFA and CFA (182 cases assigned to each), but none met the RMSEA (Root Mean Square Error of Approximation) criterion (≤ 0.08). All versions of the UDI had high internal consistency (Cronbach's α > 0.90) and were strongly correlated (Pearson's r > 0.7) with both GARS and GCPS disability scores, indicating concurrent validity. Conclusions. A brief, generic self-reported disability questionnaire was found to be valid and to possess good psychometric properties. The UDI has a single factor structure and either a 6-item, 7-item or 8-item version can be used to measure disability. For brevity and parsimony, the 6-item UDI is recommended, but further testing of all versions is warranted. Conflicts of interest. No conflicts of interest. Sources of funding. No funding obtained

Background. Magnetic resonance imaging (MRI) algorithm identifies end stage severely degenerated disc as ‘black’, and a moderately degenerate to non-degenerated disc as ‘white’. MRI is based on signal intensity changes that identifies loss of proteoglycans, water, and general radial bulging but lacks association with microscopic features such as fissure, endplate damage, persistent inflammatory catabolism that facilitates proteoglycan loss leading to ultimate collapse of annulus with neo-innervation and vascularization, as an indicator of pain. Thus, we propose a novel machine learning based imaging tool that combines quantifiable microscopic histopathological features with macroscopic signal intensities changes for hybrid assessment of disc degeneration. Methods. 100-disc tissue were collected from patients undergoing surgeries and cadaveric controls, age range of 35–75 years. MRI Pfirrmann grades were collected in each case, and each disc specimen were processed to identify the 1) region of interest 2) analytical imaging vector 3) data assimilation, grading and scoring pattern 4) identification of machine learning algorithm 5) predictive learning parameters to form an interface between hardware and software operating system. Results. Kernel algorithm defines non-linear data in xy histogram. X,Y values are scored histological spatial variables that signifies loss of proteoglycans, blood vessels ingrowth, and occurrence of tears or fissures in the inner and outer annulus regions mapped with the dampening and graded series of signal intensity changes. Conclusion. To our knowledge this study is the first to propose a machine learning method between microscopic spatial tissue changes and macroscopic signal intensity grades in the intervertebral disc. No conflict of interest declared.  . Sources of Funding. ICMR/5/4-5/3/42/Neuro/2022-NCD-1, Dr TMA PAI SMU/ 131/ REG/ TMA PURK/ 164/2020. A part of the above study was presented as an oral paper at the International Society for the Study of Lumbar Spine (ISSLS) meeting held on 1–5. th. May 2023, Melbourne, Australia

Background and study purpose. Low mood and distress are commonly reported with by people with persistent musculoskeletal pain and may be mislabelled as ‘depression’. In order to understand how pain-related distress is conceptualised and managed in primary care consultations, we explored understanding of pain-related distress and depression from the perspectives of people with persistent musculoskeletal pain and general practitioners (GPs). Method and results. Semi-structured interviews with 21 GPs and 21 people with persistent musculoskeletal pain were conducted. The majority of people with pain had back pain (15/21). Data were analysed thematically using constant comparison techniques. Participants described challenges distinguishing between distress and depression in the context of persistent pain but described strategies to make this distinction. Some people with pain described how acceptance of their situation was key, involving optimism about the future and creation of a new identity. Some GPs expressed ‘therapeutic nihilism’, with uncertainty about the cause of pain and thus how to manage people with both pain and distress, whilst GPs who could identify and build on optimism with patients described how this could help the patient to move forwards. Conclusion. This study offers a model for the primary care consultation with patients presenting with pain-related distress. GPs should recognize the impact of pain on the patient, support the person in acceptance of the pain, explore how the person feels about the future, encourage optimism, and support self-management strategies. Conflicts of Interest: No conflict of interests. Sources of funding: This study was funded by Versus Arthritis – grant number: 22454; Carolyn A Chew-Graham is part-funded by NIHR Applied Research Collaboration (ARC) West Midlands

Purpose of study. Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Background. Thirty physiotherapists working in a community musculoskeletal service were purposively invited to participate in semi-structured interviews. Data was transcribed and thematically analysed. Methods and Results. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning was achieved by 63% of participants, 76% used lay terminology and 73% used explicit language. Only 43% framed the questions before asking them and only 16% combined all four dimensions. Whilst most participants (n = 25) felt comfortable asking general CES questions, 50% reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Conclusion. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained. Previously presented poster at BritSpine 2021 and VPUK 2021

Purpose of study and background. Spinal muscle area (SMA) is often employed to assess muscle functionality and is important for understanding the risk individuals may have of developing back pain or the risk of postural instability and falls.. However, handgrip strength (HGS) has also been utilized as a measure of general muscle capacity. This study aimed to examine the relationship between SMA and HGS to assess whether the latter could be used as an accurate indicator of the former. Methods. 150 participants (75 males and 75 females, aged 47–70 years) were selected from the UK Biobank dataset. Handgrip strength values were extracted and averaged over left and right values. Abdominal MRI images were examined and cross-sectional area of the erector spinae and multifidus determined at the L3/4 level and summed to provide a total muscle area. Results. HGS and SMA (mean±sd) were 39.6 ± 7.4 kg and 4664 ± 868 mm. 2. for males and 24.7 ± 5.9 kg, and 3822 ± 579 mm. 2. for females. Pearson correlation between HGS and SMA was r = 0.41 for males (p = <0.001), r = 0.40 for females (p = <0.001), and r = 0.61 for the combined groups (p<0.001). Conclusion. Significant correlations were found between HGS and SMA for individual sexes and combined groups. However, although HGS may be a useful measure for predicting modifications in group responses in spinal muscle function, for example, following an intervention, it does not have the power to confidently predict muscle values at an individual participant level. Conflicts of interest: No conflicts of interest. Sources of funding: Prince Sattam University, KSA, provided a PhD scholarship for Salman Alharthi