To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Background. Back pain has become a worldwide problem and excessive, repetitive rotation has been shown to cause tissue damage. A sleeping posture similar to that of the foetal position has been suggested to limit unnecessary rotation of the lumbar spine. The Rophi™ cushion, utilises this theory to provide spinal alignment and improved sleeping posture. This study aims to assess the subjective experience and biomechanical effects of the Rophi™ cushion in participants with simple mechanical lower back pain (LBP). Methods & Results. Fifteen participants (aged 44 ± 9.7 years) with simple mechanical LBP were recruited using the Red Flags screening form. The kinematics of the pelvis, lower limbs, lumbar and thoracic spine were analysed in six degrees of freedom whilst the participants lay in a semi-foetal position. Visual analogue scales were used to measure participant pain and discomfort levels during sleep pre and post a one week cushion intervention. Kinematic results show the main significant difference in joint angles occurred at the hip in all three planes, and between the lower lumbar region and the pelvis in the coronal plane. Subjective experience showed a reduction in the number of days with poor sleep quality and a significant reduction in frequency and intensity of lower back pain and stiffness when waking. Conclusions. Through repositioning of the hips and lower lumbar spine, overall it appears the individual is moved towards a more neutral position when using the Rophi™ cushion and a one week intervention shows a significant improvement in lower back pain on waking. Conflicts of Interest. None. Source of Funding. Funded by the NWDA Innovation voucher scheme. This abstract has not been previously published in whole or substantial part and has not been previously presented at a national meeting

Introduction and Aims: Lower back and/or leg pain is a symptom of a number of pathological conditions involving lumbosacral nerve roots. Disc herniation is one of the most common causes of LBP (after mechanical back pain). There is controversy regarding the progression of disc degeneration and/or lower back pain to symptomatic disc prolapse over time. Method: The aim of the study was to determine the natural progression of patients with lower back pain/disc degeneration established clinically and on MRI to symptomatic disc herniation over three to six years. Total of 970 patients who had an MRI scan between January 1998 and September 2000 were included in the study. Information about disc pathology, level and number of discs involved were recorded from MRI scan reports. A short questionnaire was sent to all patients. It contained 10 questions regarding current status of pain and neurology, any treatment in form of back injection and operation, current occupation and smoking status. Results: The collected data was analysed using standard statistics software (SPSS). The results will be discussed. Conclusion: The information provided by this study will be useful in judging the natural progression of lower back pain and/or disc degeneration to a symptomatic prolapse intervertebral disc. It will also be useful in medico-legal cases where patients had pre-existing disc degeneration and subsequently developed disc herniation over time

Introduction and Aims: Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that a detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. Method: A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually, to reach the diagnosis and plan the management. Sixty consecutive lower back pain and/or radiculopathy patients were included in the study. All the patients were seen by two orthopaedic registrars. Detailed history was taken by one and clinical examination was performed by the other registrar. A provisional diagnosis was made by both registrars based on their information. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results: The gathered information was analysed using standard statistics software. The data indicates that clinical examination on its own was non-contributory in reaching diagnosis and plan the management. All information obtained by history alone correlated well with MRI results. The full results and cost implications will be discussed. Conclusion: Routine clinical examination of spine can be omitted without compromising the patient care, where clear history is available to reach diagnosis and plan the management. Clinical examination should be performed on those patients who need surgery to document the pre-operative neurology

Aim of study: ‘Dark discs’ (intervertebral discs with normal shape and height but low signal intensity on T2-weighted MRI) are believed by some authors to represent an early stage in the degenerative process although other authors have suggested that they are simply an appearance of the normal aging process. This study addresses the above question by investigating the correlation between disc morphology on MRI of the lumbar spine (‘dark disc’ or obviously degenerative signs such as annular tear, loss of disc height and shape and end plate changes) and the distribution of lower back pain. Background: It is generally accepted that spinal levels appearing degenerate on MRI may act as ‘pain generators’ either directly or indirectly (by affecting adjacent structures or levels). Furthermore, histopathologic and discographic studies have shown transmition of specific patterns of somatic pain from degenerate spinal levels. Methods: 231 consecutive patients (mean age: 45 years, SD:15.9) presenting with mechanical lower back pain of more than six months duration completed topographic graphs of the distribution of their back pain (categorised for this study as upper-, mid-, low-lumbar and sacroiliac area pain) and underwent an MRI of the lumbar spine. Chi-square test was used to investigate the association between presence of abnormalities at any spinal level and pain at any of the considered body areas. Two sets of analyses were performed: one including ‘dark discs’ in the ‘pain generators’ group and the other excluding the ‘dark discs’ from this group. Results: When the ‘dark discs’ were not considered as ‘pain generators’ the only association to reach statistical significance was that between L5/S1 abnormalities and mid-lumbar pain (P=0.02). However, inclusion of the ‘dark discs’ in the ‘pain generators’ group increased the strength of the association between L5/S1 abnormalities and mid-lumbar pain (P< 0.01) and also resulted in the associations between L3/4 and L4/5 level abnormalities and sacroiliac area pain reaching statistical significance (P=0.02 and P< 0.01 respectively). Conclusion: The significant statistical effect of considering ‘dark discs’ as ‘pain generators’ on the association between specific spinal level abnormalities and presence of back pain in well-defined areas suggests that the MRI appearance of a ‘dark disc’ should be considered an early stage in the degenerative process and not simply an effect of normal aging

A statement of the purposes of the study and background. Lower back pain (LBP) is one of the ten leading causes of disease burden globally, producing significant detrimental effects on physical and emotional wellbeing whilst having a substantial economic burden for society. There is an inverse relationship between socio-economic status and pain prevalence. The effectiveness of a locally run ‘Back to Fitness Programme’ (6-week education and exercise programme) in the most deprived local authority area in England was evaluated. A summary of the methods used and the results. Patients at Blackpool Hospitals NHS Trust over a 6-month timeframe were included. Initial data were collected from 49 patients (mean age 53.4 years, 67% female). The amount of final data collected varied per outcome measure due to a range of factors. Participants reported the programme had helped with their understanding of pain (n=16, 100%), ability to move around and function (n=15, 94%), and level of pain (n=14, 88%). Looking at Roland Morris Disability Questionnaire scores (n=17), 88% (n=15) of patients indicated a reduction (n=12, 71%) or no change (n=3, 18%) in perceived disability. The Pain Self Efficacy Questionnaire (n=18) showed that 78% (n=14) of participants perceived an increase in their average level of confidence to move despite pain. There was an overall improvement in understanding of pain reflected by Revised Neurophysiology of Pain Questionnaire scores (n=44): 89% (n=39) improved (n=36, 82%) or did not change (n=3, 7%). Regarding lumbar flexion post-programme (n=17), 77% (n=13) of participants demonstrated an improvement (n=9, 53%) or no change (n=4, 24%). Conclusion. The majority of clinical outcomes improved following participation, predominantly in relation to understanding of pain. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by The University of Central Lancashire in partnership with The Blackpool Teaching Hospitals NHS Foundation Trust

Background. There are no published studies investigating predictive values of psychological distress on effectiveness of epidural injection. Aims. To evaluate response to epidural injection (EI) in patients with chronic lower back pain (CLBP) with and without psychological distress. Methods. 96 patients with CLBP were recruited to this prospective cohort study. They had preoperative level of distress measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ); back related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal EI comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. Results. There were 62.5% not-distressed patients, 3.1% somatising, 15.6% depressed and 18.8% with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Distress was associated with worse MPQ and ODI. Average VAS and MPQ improved significantly at 6 and 26 weeks. Mean change of ODI was significant but less than MCIC. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was significant predictor of VAS-MCIC at 6 weeks while MZI and MSPQ at 6 months. None could predict this outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC with 53%-sensitivity and 78%-specificity. MZI was significant predictor of ODI-MCIC but not individually.88% patients were satisfied with the treatment at 6 weeks and 63% at 6 months (significantly higher rate if somatising). Conclusions. Early psychological screen was correlated with outcome following epidural injection in CLBP and capable of predicting some response to treatment. Minimal, short-lived improvement of distress was not related to post-treatment CLBP measures

The objective of this trial was to investigate the efficacy of a Comfrey root extract cream in patients with acute upper or lower back pain. The study was conducted as a double-blind, multi-centre, parallel group design RCT over a period of 5 ± 1 days. The patients (n=120, mean age 36.9 years, 46.7 % female) were treated three times a day, 4 g cream per application. The trial included four visits. The primary efficacy variable was the area-under-the-curve (AUC) of the Visual Analogue Scale (VAS) on active standardised movement values at visits 1 to 4. Among the secondary objectives were back pain at rest (VAS), pressure algometry (pain-time curve; AUC over 5 days), global assessment of efficacy by the patient and investigator, and functional impairment measured with the Oswestry Disability Index. There was a significant treatment difference between verum and placebo. In the course of the trial the primary variable decreased on average (median) about 95,2 % in the Comfrey extract group and 37.8 % in the placebo group. The results separated by pain location show an equivalent effect of comfrey extract: Regarding pain at rest, in lower back pain a reduction of 98% were observed, in upper back pain 96.9%. The results of this RCT were clear-cut and consistent across all variables. Comfrey root extract cream showed a remarkably potent and clinically relevant effect in reducing acute back pain. For the first time a fast-acting effect of the ointment (1 hour) was also witnessed in this trial. Conflicts of interest and sources of funding. CS and MT are employees of Merck Selbstmedikation GmbH, the sponsor of the presented clinical trial. BMG is CEO of CRM Pharmaberatung GmbH, the CRO of the presented clinical trial

Aim: To determine the effectiveness of therapeutic lumbar facet joint injections in patients with chronic low back pain. Methods: Eighty-six patients with refractory chronic low back pain were randomly assigned to receive facet joint injection using local anaesthetic and corticosteroid suspension under fluoroscopic guidance after clinical and radiological assessment. The main parameter for the success or failure of this treatment was the relief of the pain. Pain intensity was assessed with a visual analog scale (VAS) and changes in function and quality of life were assessed by the revised Oswestry Disability Questionnaire (ODQ) at baseline and during follow-up after injection. Results: Patients reported lasting pain relief, better function, and improved quality of life following injection. Cumulative significant relief following injection was 91.9% up to 1 to 3 months, 81% for 4 to 6 months, 34% for 7 to 12 months, and 10% after 12 months, with a mean relief of 6.5 +/− 0.76 months. There was significant improvement noted in overall health status with improvement not only in pain relief, but also with physical, functional, and psychological status, as well as return-to-work status. No complications were noted following injection. Conclusion: The results of this study demonstrate that intra-articular facet joint injection appear to have a beneficial medium-term effect in patients with chronic lower back pain and may therefore be a reasonable adjunct to non-operative treatment

Purposes and background

Low back pain (LBP) is a common condition with substantial associated disability and costs, best understood using a biopsychosocial approach. Research demonstrates LBP beliefs are important, with biomedical beliefs influencing practitioner's management. LBP beliefs can be inconsistent amongst medical students. The aim of this study was to investigate graduate medical student's beliefs of LBP and what influences them.

Purpose: Clinical practice guideline (CPG) concordant treatment (Ctx) has been shown to be more effective than CPG discordant care (Dtx) in a heterogeneous cohort of patients with acute lower back pain (ALBP). However, patients with underlying spine pathology (e.g. stenosis, disc degeneration, facet joint arthropathy) or without identifiable spine pathology may all present solely with ALBP. At present, it is unknown if underlying spine pathology influences the outcome of Ctx. The purpose of this study was to determine if Ctx is more effective than Dtx in patients with differing underlying spine pathology who present with ALBP. Method: A Two-arm, randomized control trial with stratified analysis. Inclusion: Ages 19–59; QTFSD I, II ALBP < 4 weeks. Exclusion: “Red Flag” conditions, comorbidities contraindicating Ctx. The primary outcome was the difference between Ctx and Dtx Roland Morris Disability (RDQ) scores at 16 weeks post baseline between study groups. Secondary outcomes: differences in Bodily Pain (BP), Physical Functioning (PF) SF-36 domain scores at 16 weeks. Patients were assessed by a spine physician and randomized to Ctx or Dtx. Patients were stratified on the basis of CT or MRI evidence of:. spinal stenosis;. disc degeneration;. facet joint arthropathy; or. no identifiable pathology. Hospital / University Ethics approval was obtained. Results: Eighty-eight patients were recruited; 39 in Ctx & 38 in Dtx group completed the study. Baseline prognostic variables were evenly distributed between groups. Outcomes: mean difference in 16 week RDQ, BP and PF scores between Ctx and Dtx was statistically greatest in group 4 (p< 0.001). There was no significant clinical improvement in RDQ, BP or PF scores in either the Ctx or Dtx in group 2. Conclusion: Ctx was more effective than Dtx in patients with no identifiable spine pathology and ineffective and equivalent to Dtx in patients with underlying disc degeneration

Recently a great amount of research has been conducted into fatigability of paraspinal muscles in relation to Lower Back Pain (LBP). Additionally relationships have been observed between a general level of “fitness” and LBP. This research project aimed to evaluate the influence of aerobic fitness and health on lower back muscle function as measured by Electromyographic (EMG) spectral parameters. Participants undertake a series of psychometric tests, anthropometric data collection, EMG spectral analysis of the paraspinal muscles at lumbar and thoracic regions, and an aerobic fitness test. The EMG test involves a 30-sec isometric pull against a load normalised for weight. The spectral half-width, initial median frequency and median frequency slope are calculated. Participants are given biofeedback and exercise advice. Participants in this study were of above average fitness level compared to normative data. Other anthropometric data were similar to previous work conducted within this department. Preliminary regression analysis results have revealed no relationships between aerobic fitness level and EMG parameters, a finding that is counter to current beliefs on LBP and fitness, however it was observed that age did significantly influence lumbar spectral variable values (p = .002). A similar psychological profile was observed for all fitness levels

Introduction Dynesys flexible stabilisation was developed by Giles Dubois in 1992, and first used in 1994 (. 1. ). Our unit has undertaken 375 operations to date. We report a consecutive series of 200 patients who underwent Dynesys flexible stabilisation in the management of intractable lower back pain. Methods Access to our spinal service is exclusively from a back assessment centre run by a triaging nurse practitioner who works closely with the senior author. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. Patients were only accepted for the study if exhaustive conservative management had failed. They underwent operation by the senior author between September 2000 and March 2003. Patients were divided into two groups: Group 1 – Cases where implantation was used as an adjunct to other procedures including decompression, discectomy, or posterior lumbar interbody fusion. (32 male, 36 female, Mean age 56years (range 31–85)) Group 2 – Patients with back pain and/or sciatica in which no other procedure was used. (65 male 67 female, Mean age 58years (range 27–86)) All patients were profiled prospectively using the Oswestry Disability Index (ODI), SF36 and Visual Analogue Scale (VAS). Patients were reviewed post-operatively using the same measures at 3, 6 and 12 months, and yearly thereafter. Follow-up was 95% at 2 to 5 years. Results Group 1 – Mean ODI fell from 54 pre-op to 24 at four years. Mean SF36 improved from 43 pre-op to 56 at four years Group 2 – Mean ODI fell from 49 pre-op to 28 at four years. Mean SF36 improved from 40 pre-op to 62 at four years. Similar trends were observed in both groups at five years with these favourable scores tending back towards pre-operative levels. Screw failures, either loosening or fracture, occurred at a rate of 15% over the follow-up period. Discussion Our results support the use of flexible stabilisation as an alternative to spinal fusion. There is currently no consensus on absolute indications for the procedure however. Such indications can only be defined following clinical outcome. Perceived indications were based on contemporary understanding of the biomechanical effects of the construct. Further investigation of these variables is clearly desirable. Screw failures (15%) have detracted from the overall success, although the relationship between such failures and poor outcomes is complex and difficult to elucidate at the current time. The virtue of flexible stabilisation over fusion includes avoidance of domino effect, reversibility and possible healing of a painful segment. The key issue is whether flexible stabilisation is as effective and this requires prospective randomised controlled investigation, both against fusion, and against conservative management. We feel our results in this difficult group of patients are reasonable and continue to use it in our practice

We report a consecutive series of 200 patients who underwent Dynesys flexible stabilisation in the management of intractable lower back pain. Methods: Patients were only accepted for the study if exhaustive conservative management had failed. They underwent operation between September 2000 and March 2003. Patients were divided into two groups:. Group 1 - Cases where implantation was used as an adjunct to other procedures including decompression, discectomy, or posterior lumbar interbody fusion. (32 male, 36 female, Mean age 56years (range 31–85)). Group 2 - Patients with back pain and/or sciatica in which no other procedure was used. (65 male 67 female, Mean age 58years (range 27–86)). All patients were profiled prospectively using the Oswestry Disability Index (ODI), SF36 and Visual Analogue Scale (VAS). Patients were reviewed post-operatively using the same measures at 3, 6 & 12 months, and yearly thereafter. Follow-up was 95% at 2 to 5 years. Results: Group 1 – Mean ODI fell from 54 pre-op to 24 at four years. Group 2 – Mean ODI fell from 49 pre-op to 28 at four years. Similar trends were observed in both groups with a fall in VAS and improvement in SF36. Discussion: Indications can only be defined following clinical outcome. Perceived indications were based on contemporary understanding of the biomechanical effects of the construct. Further investigation of these variables is clearly desirable. Screw failures (15%) have detracted from the overall success. The virtue of flexible stabilisation over fusion includes avoidance of domino effect, reversibility and possible healing of a painful segment. The key issue is whether it is as effective and this requires prospective randomised controlled investigation, both against fusion, and conservative management. We feel our results in this difficult group of patients are reasonable and continue to use it in our practice

Purpose and background

Over two-thirds of pregnant women experience low back pain (LBP) that interferes with everyday activities, work and sleep. Acupuncture appears a safe, promising intervention but there are no high quality trial data, regarding its clinical or cost-effectiveness in comparison to standard care.

Purpose and background

Whether to order an MRI scan or not for patients with low back and leg pain (LBP). Resources are limited. Waiting for diagnostic imaging impacts time to treatment and may be critical to the “18 week target”. We have looked into devising a system in which we can ordered MRI scans for patients with LBP pre-clinical assessment based on questionnaire and accessing their referral letter.

Decision to operate for lumbar nerve root compression is usually based on the clinical findings and MRI scan evidence of nerve root compression. Decision-making is difficult in the subset of patients with pain in the groin, buttock or thigh with L5 and S1 nerve root compression as evidenced by MRI scan. We retrospectively studied 125- diagnostic nerve root injections, of which there were 12 patients who had pain in the groin, thigh or buttock and their MRI scans were reported as nerve root (11 L5 & 1 S1) compression by the radiologist. All these 12 patients were subjected to injection of the affected nerve root with bupivacaine and methylprednisolone under the guidance of image intensifier. Of these 5 (42%) of them had temporary relief of the symptoms; and all of them underwent surgical decompression of the affected nerve root. They were followed for an average of 12 months with satisfactory results. This demonstrates the importance of nerve root injections as a diagnostic tool in patients with atypical symptoms with a positive MRI scan.

Statement of Purpose

It is well known that individuals with a history of low back pain (hLBP) exhibit altered movement patterns that are caused by changes in neuromuscular control. Postural disturbance provides an effective method for creating these differentiable movement patterns. This study has explored the response of the lower limb and spine to a translational perturbation similar to that experienced on public transport in healthy volunteers and those with hLBP.

We report a consecutive series of 352 patients with back pain treated by Dynesys flexible stabilisation between July 2000 and November 2004, to include perceived indications, surgical techniques and complications. A detailed analysis of the first 120 cases with minimum follow up of 2 years is included. Our unit has undertaken 352 operations to date, and this communication reports all cases. Follow up is to 48 months.

All patients were profiled prospectively using the Oswestry Disability Index, Euroquol, SF36, Pain analogue scale, Pain chart and modified Zung. The same measuring instruments were used at review for which follow up was 100%

The procedure involves paired bilateral pedicle screw instrumentation above and below the level of perceived pathology, with each screw pair connected by load relieving carbopolyurethane flexible spacers, in conjunction with a tension band polyethylene cord passed through the spacer. This construct is then held under tension with screws in the main pedicle screws.

All patients are profiled at entry to the hospital service using a proforma which includes the measures outlined above. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. All our cases have failed conservative treatment before enrolling for surgery.

There was significant improvement in symptoms for most of the patients in the series. However clear patterns emerged as to those cases in which Dynesys is contra-indicated.

This is the largest series of cases reviewed so far in the literature.