Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Purpose and Background. The MOCAM study is a major prospective questionnaire-based study investigating the relationship between low back pain (LBP) patient outcomes and non-specific treatment components, i.e., therapeutic relationship, healthcare environment, incidental treatment characteristics, patients' beliefs and practitioners' beliefs. Participating acupuncturists, osteopaths, and physiotherapists from the NHS and private sector have been asked to recruit at least 10 patients into the study. This paper aims to analyse current recruitment rates from MOCAM and identify barriers and facilitators to effective recruitment. Methods and Results. Recruitment has taken place over 15 months. Invitation letters or emails were sent to individual practitioners identified using online search tools and professional networks. Recruitment rates were analysed descriptively. Within the private sector, response rates (number participating/number invited) are: acupuncturists 3% (49/1561), osteopaths 6% (53/912), physiotherapists 4% (40/1048). Private sector practitioners have each recruited on average 1, 4, and 2 patients into the study respectively. Within the NHS, the response rates are: acupuncturists 100% (2/2), osteopaths 8% (1/13), physiotherapists 63% (44/70). NHS practitioners have each recruited on average 4, 3, and 2 patients respectively. Conclusions. Recruiting practitioners has been challenging. While the response rates in the NHS are higher than in the private sector the absolute number of acupuncturists and osteopaths participating from the NHS is very low. This may be due to changes in the NHS commissioning landscape. However, further investigation is required to confirm this. The higher recruitment rates of patients from NHS settings may reflect different patient populations across sectors. No conflicts of interest. Funding: This work was supported by Arthritis Research UK Special Strategic Award grant number 20552

Background and purpose. Adherence to clinical guidelines produces greater improvement in disability in patients with low back pain (LBP), but a wide variation in physiotherapists' adherence has been documented repeatedly. The aim of the study was to investigate the adherence to National Clinical Guidelines for LBP among Danish physiotherapists with regard to three key guideline domains: 1) activity, 2) work, and 3) psychosocial risk factors. Additionally to investigate whether adherence differed between physiotherapists working in private clinics and physiotherapists working at public healthcare centres. Methods. A cross-sectional online survey was conducted with 817 Danish physiotherapists. Adherence to the three guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the chi-squared test. Results. Response rate was 29%. The proportions of physiotherapists giving advice that was strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Physiotherapists working at public healthcare centres were more likely to manage patients strictly in line with National Clinical Guidelines for assessing the psychosocial risk factors. Regarding the two other domains, there was no significant difference between the two groups in terms of adherence. Conclusion. Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This confirms the importance of identifying barriers to implementation of the National Clinical Guidelines in physiotherapy care for patients with LBP, including implementation of the inherent bio-psychosocial model. Conflicts of interest: None. Sources of funding: None

Aims

Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour. Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs. . The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery. Cite this article: Bone Joint J 2014;96-B:1693–8

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To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Background and purpose:. Inconsistent outcome reporting is a problematic issue in systematic reviews of clinical trials in non-specific LBP (NSLBP). To facilitate statistical pooling and improve reliability of reviews, the development of a core outcome set (COS) is recommended. In 1998, Deyo et al. proposed a standardized set of domains and measurement instruments for LBP clinical research. An international steering committee (ISC) was formed to update 1998 recommendations, and to determine, at first, which outcome domains should be included in a COS for clinical trials in NSLBP. Methods:. The ISC used the OMERACT framework 2.0 to draw a list of potential core domains. This list was presented in a 3-round Delphi survey, in which researchers, clinicians and patients were invited to participate. Criteria for consensus were established a-priori and quantitative responses were analysed together with arguments provided by Delphi participants. The ISC discussed the results and made final decisions. Results:. 280 ‘experts’ were selected and invited to participate in the Delphi survey. Response rates in the three rounds were: 52%, 50%, and 45%. A list of 41 potential core domains was presented but 28 of them did not reach sufficient consensus to be presented in the third round, where overall consensus was reached on three domains: ‘physical functioning’, ‘pain intensity’ and ‘health-related quality of life’. Conclusion:. ‘Physical functioning’, ‘pain intensity’ and ‘health-related quality of life’ were included in this COS, together with the reporting on ‘number of deaths’. The next step in the development of this COS will be to determine which measurement instruments are most fit-for-purpose to measure these outcome domains

Background:. Low Back Pain and Neck Pain rank 1 and 4 on the causes of years lost to disability (YLDs) in the UK. Treatment options are broad including popular approaches such as chiropractic care but with NHS funding limited to recent initiatives such as Any Qualified Provider (AQP). Method:. Eleven chiropractic practices with AQP contracts took part in the study. As part of routine clinical practice, patients are entered onto a web based patient reported outcome system that sends automated e mails links to questionnaires, prior to the initial visit (includes the Bournemouth Questionnaire (BQ) and STarT Back, and at 14, 30 and 90 days (BQ and Patient Global Impression of Change (PGIC)). Data from subjects consenting for such use were used in the analysis. Results:. Three thousand three hundred thirty nine patients filled out baseline questionnaires, one third of which were NHS. Response rates at 90 days were 33 and 23% in NHS and private groups respectively. NHS referral status was associated with reduced adjusted odds only at 14 days whereas at 30 and 90 days referral groups were equally likely to have improved. Chronicity, lower baseline BQ scores and not improved at previous follow up points were associated with poor recovery. High-risk STarT Back patients were associated with poorer recovery compared to low risk patients but only in the NHS group. Conclusion:. Factors predicting favourable outcomes were similar between NHS and private groups. At most only 35% of the variance was explained with dominance from non-modifiable prognostic factors

Background:. Combined physical and psychological (CPP) programmes are widely recommended for Chronic Low Back Pain (CLBP) patients. Patients with longstanding CLBP participating in a two-week CPP-programme improve in functional status and quality of life and the results are maintained for at least one year. First indications of maintenance of improved patient-reported outcomes are shown at two-year follow-up assessment. Purpose:. Evaluation of the long-term (at least five years of follow up) maintenance of positive results of a short, intensive, evidence based CPP-programme. Methods and Results:. A consecutive cohort study was performed, with a mean follow up of 6.5 years (range: 5.5–7.5). At follow up a response rate of 85% (n=277) was achieved. At pre-treatment the mean age was 46.1years (SD9.3) and the mean CLBP-duration 12.3years (SD10.9). Primary outcome was functional status (Oswestry Disability Index [ODI;0-100]). Secondary outcomes: pain intensity, quality of life, and satisfaction. A Repeated Measures analysis of variance was used to identify changes over time. The mean ODI-score showed improvement at post-treatment and maintenance of results over time (ODI df[1,276], F = 0.146, p = 0.703). Secondary outcomes showed the same pattern. At long-term follow up almost half of the CLBP-patients (45.3%) reached a functional status equivalent to an acceptable, normal healthy population value (ODI≤22), comparable to the 1-year follow-up assessment. 80.1% of the participants are satisfied with treatment results and 76.2% would recommend the programme to family/friends. Conclusion:. Long-term effectiveness of a CPP-programme is demonstrated. Patients improve during the programme and 1-year follow-up results are maintained after 6.5 years follow up

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

Background. The available treatments for NSLBP (Non-Specific Low Back Pain) provide, typically, small to moderate average benefits to patients. The aim of this pilot cluster RCT was to test the hypothesis that the use of a patient decision aid together with an informed shared decision making consultation would produce better outcomes in satisfaction with treatment at four month follow-up. Methods. We developed a DSP (Decision Support Package). We randomised the physiotherapists and trained those in the intervention arm in informed shared decision making and communication. Participants were recruited from a local physiotherapy department and those allocated to an appointment with an intervention therapist were sent a copy of the DSP in the post. Participants then attended their appointment as usual. Results. We recruited 148 participants, 85 (57%) participants were assigned to the DSP arm. There was an 80% response rate for the primary outcome, satisfaction with treatment. The adjusted odds ratio of satisfaction with treatments from participants in the DSP arm against those in the control arm was 0.54 (95% CI: 0.19, 1.53). The difference between the treatment arms for the RMDQ (Roland Morris Disability Questionnaire) at four month follow-up was −2.27 (95% CI: −4.47, −0.08). Conclusions. There were no differences in our primary outcome measure between the groups. There was a statistically significant and clinically important difference in the RMDQ. These data have informed our decision about progression to a full trial application

Northumbria Healthcare NHS Trust, Ashington, UK. To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain. Prospective study. 23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan. Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment). The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23). Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB

To audit patient satisfaction throughout the perioperative period amongst emergency and elective admissions in the spinal team. 92 patients were identified whom underwent operations within a 3 month period using the operating database. A self administered postal questionnaire was sent to assess preoperative waiting time, quality of preoperative assessment and information given, assessment of their admission, their experience throughout hospital stay and the quality of their post operative assessment and discharge. Patient reported outcomes (PROMS). Response rate 35% (32/92) of which 24 (14F 10M) were elective admissions and 8 emergency admissions (2F 6M). Average wait for elective procedure was 5.7 weeks (median 2). 63% of elective patients were seen in prescreening clinic and 79% of these received an information booklet prior to operation. 22% of patients had delayed discharge due to non clinical causes including awaiting transport, awaiting medications and physiotherapy clearance. 88% of patients reported they were given adequate information regarding post-operative daily activities. 79% of elective patients reported seeing a doctor on the day of their discharge however only 38% reported seeing a physiotherapist postoperatively. This fell to 0% for patients operated on a Friday. Although 94% of patients reported that they were satisfied with the overall care they were given, they reported certain aspects of their clinical care being less than optimal. Trust wide assessment of patient reported outcomes to assess and improve the quality of care against national guidelines. Ethics Approval: Self questionnaire approved by ethics committee

Background. The outcome of studies on back pain is usually measured at specific intervals (1 month, 3 months, etc.) However, because LBP is a recurring condition it would be more relevant to identify outcome in relation to course over time. A new data collection tool was recently developed (SMS-Track), allowing this to be done. Aims. present the SMS-Track system. give some examples of how the course pattern varies between patients with back pain. Methods. Each week for a year 80 patients with LBP participating in an RCT responded to two automated SMS-questions relating to “days of pain” and “days of sick-leave” during the preceding week. Patients sent one text message in return for each question with an answer from “0” to “7” days. Replies were automatically stored in a data file that later was used for analysis. Examples of graphs will be given, to show how patterns can be viewed for each individual patient. Results and discussion. The frequent points of data collection made it possible to view each patient's specific reporting pattern. These patterns showed that some patients improve immediately, whereas others have various types of fluctuating patterns. The sick-leave pattern did not necessarily follow the pain pattern. Examples will be given in the poster. Conclusion. SMS-track was found to be a useful tool for obtaining repeated measurements at short intervals over long periods of time allowing detailed insight into various disease patterns. This appears particularly interesting in diseases of a recurring nature. In addition, this method has a very high response rate

Background. The prevalence estimates of LBP are so far well documented. However, only few longitudinal studies have described the variability of LBP in the same population over time. Therefore, little is known about the course of LBP at the individual level. Purpose. The aim of this study was to describe changes in low back pain (LBP) reporting over an eight-year period in a cohort of adult Danes. Methods. A cohort of 625 men and women, aged 40, was randomly sampled to be representative of the general population. Questions about LBP were asked at the age of 41, 45, and 48. Two definitions of LBP were investigated: “Trivial LBP” (any reported LBP during the past month) and “Non-trivial LBP” (reporting more than 30 days with LBP during the past year with consequences: sick leave, healthcare contacts or limitations in participation). Prevalence rates at the three different times were reported and the course of LBP was visualized. Results. The response rate was 66%, 56%, and 47%, respectively. The prevalence rates of different types of LBP did not change significantly across this eight-year period (trivial: 42%, 48%, 40%; non-trivial: 18%, 20%, 20%). Around 50% of those with LBP reported the same type of LBP next time and 10-25% had a fluctuating pattern of reporting. This was true for both definitions of low back pain. Discussion. This study confirms that LBP is a recurrent condition for a large proportion of people in the forties. It also confirms that the presence of LBP indicates a major risk of future LBP. This abstract has not previously been published in whole or substantial part nor has it been presented at any national meeting

Aims

The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR.

Purpose of Study/Background. To identify whether patients were satisfied with the overall educational component of the specialist nurse (CNS)/occupational therapist (OT) led pre-operative assessment clinic in order to identify areas which required improvement. The pre-operative specialist nurse led clinic was set up in 2002. The aim was to provide high quality information to patients undergoing elective spinal surgery in order to manage expectations and optimise post-operative recovery. Initially the clinic was specialist nurse led however, in 2006 occupational therapy input was introduced in order to provide an increased depth of information in regard to function and activities of daily living post operatively. In addition this has allowed assistive equipment to be provided pre-operatively. The format of this clinic has enhanced the patient's journey by facilitating reduced length of stay and more timely discharge. Methodology. A questionnaire was forwarded to a random sample of two hundred patients who attended for pre-operative assessment in the twelve-month period between April 2014 & March 2015. Sixty questionnaires were returned (30% response rate). Results/Summary. Patients were asked 17 questions in total, 3 general, 6 regarding CNS and 8 regarding OT. The responses were rated ‘very good’; ‘good’ ‘average; ‘poor’. In the returned audits no ‘poor’ responses were recorded. Clarity of information given: Very Good-56%; Good-39%; Average-5%. Overall experience of pre-operative assessment: Very Good-66%; Good- 32%; Average-2%. Advice given by OT: Very Good-82%; Good-16%; Average-2%. Information given by CNS: Very Good-75%; Good-23%; Average-2%. Conclusions. The results indicate that the OT and CNS specialist education sessions are considered valuable by patients. We believe that we have achieved this through good team-working in a multidisciplinary setting. Patients who attend these clinics are often anxious regarding surgery, have un-realistic expectations in relation to what to expect post-operatively. A significant number of our patients are elderly and have multiple pathologies which we take into account. The education sessions link into our patient information leaflets which, expand on this allowing patients to clarify matters and ask questions. No Conflicts of Interest. No Funding Obtained

Aims

Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery.