Purpose: The long term effects of treatment in a cohort of patients with chronic low back pain (CLBP) participating in an intensive pain management program.

Background: Cognitive behavioral treatments produce clinically relevant benefits for patients with CLBP.

Methods: The program provided by RealHealth-Netherlands is based on cognitive behavioral principles and executed in collaboration with orthopedic surgeons. Primary outcomes were daily functioning and self-efficacy. Measurements were at baseline, last day of residential program and at 1 and 12 months follow-up. A GLM procedure with repeated measures was applied to examine changes over time and to explore possible unwanted side effects. Effect sizes are analyzed using cohen’s d. Clinical relevance was examined using minimal clinical important differences (MCID) estimates for primary outcomes and quality of life. To compare results with literature Standardized Morbidity Ratios (SMR) were determined.

Results: 107 patients with CLBP participated. Mean scores on primary and secondary outcomes showed a similar pattern: improvement immediately after following the program and maintenance of results over time. Effect sizes were 0.9 for functioning and 0.8 for self-efficacy. Clinical relevancy: 79% reached MCID on functioning, 53% on self-efficacy and 80% on quality of life. Found study results were 36% better and 2% worse when related to previous research on respectively rehabilitation programs and spinal surgery for similar conditions (SMR 136% and 98%respectively).

Conclusion: The participants of this evidence based program learned to manage CLBP, improved in daily functioning and quality of life. The study results are comparable with results of spinal surgery and even better than results from less intensive rehabilitation programs.

Conflict of Interest: None

Sources of Funding: None

Introduction: Pedicle screws are now commonly used to instrument the thoracic spine and offers improved three point fixation and therefore theoretically offers better derotation of the spine during corrective manoeuvres in scoliosis surgery.

Aim: To compare thoracic scoliosis correction using either pedicle hooks or pedicle screws.

Methods: Two patient groups were studied. Data was collected prospectively and this is a review of the radiological data. All patients had structural thoracic scoliosis. Group 1, 14 patients (9 female and 5 male) mean age 14.6, were treated with posterior correction of scoliosis using the standard USS II technique using pedicle hooks and screws. Group 2, 14 patients (11 female and 3 male) mean age 15.3 were treated using pedicle screws alone to correct the apical deformity, using a variation of the original USS technique. Pre and postoperative Cobb angle, apical vertebral rotation (AVR, Perdriolle method) and apical vertebral translation (AVT) were measured. Unpaired “t” test was used to compare the magnitude of correction in both groups. The mean follow up period was 30 months (range: 27–42).

Results: The mean corrections of Cobb angle, AVR and AVT, in group I were 61.1% (range: 48.5–83.9), 33.3% (range: 8.6–100) and 62.9% (range: 43.2–91.4), respectively. In Group 2 the corrections were: 57.4% (range: 21.4–81.7), 57.2% (range:16.7–100) and 58.7% (range: 34–80.9). There were no statistically significant differences between the correction of Cobb angle or AVT in both groups (P=0.479 and 0.443 respectively). However, the pedicle screws proved to be more effective at correcting the AVR (P= 0.017). No complications occurred and correction has been well maintained with a minimum of 2 year follow-up.

Conclusion: Pedicle screws can safely and effectively replace the pedicle hooks in the classical USS technique. They are more effective at correcting the rotational deformity, although do not provide a better correction of Cobb angle. These technical results now need to be correlated with relevant clinical outcomes.

Education is now recognised as a crucial component of the management of non specific low back pain. Mostly education is carried out informally in one to one consultations with health professionals. This has draw backs as it is costly, time limited, labour intensive and biased towards the discipline, training and beliefs of the clinician. The Back Book is a realistic alternative but provides very generic neutral information mostly promoting the message that pain isn’t damage.

We would see the process as one of the facilitation of knowledge acquisition rather than a formal teaching process. The latter implies engagement and responsibility on the part of the learner, rather than a pedagogic exercise by clinician or therapist.

We propose a group based, community delivered, interdisciplinary education module in which 4 different specialists contribute to an afternoon information session aimed at informing patients about: the causes of back pain from a non disease perspective, the complexity of pain perception, the biopsychosocial model, evidence based treatment of pain and some principles of paced pain management. The focus is on dispelling myths (such as the need for MRI scanning, surgery etc.) and enabling sufferers to make improved decisions about their care.

Data from over 120 patient attendances will be presented. These indicate high acceptability and satisfaction with 92% rating the afternoon as good or excellent and only 11% claiming the session had not helped them make better decisions about future treatment.

This model is simple, relatively low cost and accessible to primary care, which is acceptable and seemingly helpful to sufferers. It appears to be a viable model for presenting information to back pain sufferers early in their illness. The aim of this is to help them make more informed decisions and to see the need to incorporate self management approaches early in their history. More data are needed to ascertain whether these are achievable goals.

Introduction: This is a report on results from the first three years of the British Spinal Registry

Background: The British Scoliosis Society supported a web based scoliosis registry in 2003. At the Britspine meeting in 2004 all four British spine societies (BSS, BASS, BCSS, SBPR) agreed to expand this to include all spinal surgical procedures in the United Kingdom. An extensive marketing and promotional campaign was targeted at all members of the four societies, and online and telephone support was provided.

Aims: To report on the clinical results from the first three years registry activity

Methods: The British Spinal Registry is a web based out-come tool, collecting basic demographic and outcome data on spinal surgical procedures in the UK. Over three years from November 2004, 1410 patient data sets were entered. The activity analysis is party carried out using the online diagnostics that are part of the web based software tool, and partly with downloaded data.

Results: 73 surgeons from 55 centres entered patient data on 1410 surgical episodes between November 2004 and December 2007. The number of patients entered per year has declined marginally, with 540 patients in the first year, 454 in the second and 416 in the third. The majority of cases entered have a low back diagnosis (842) of whom 106 were part of a BASS audit on discectomy. Of the low back cases 40% had disc herniation and 7.4% had previous surgery. The complications included dural tear (3.7%), nerve root injury (0.4%) and infection (1.1%). The BASS study showed that 70% of UK surgeons were not using intraoperative radiographic localisation of surgical level. There were 448 deformity cases, and of these 223 were idiopathic scoliosis, 49 neuromuscular and 20 congenital. 57% had posterior surgery, 20% anterior and 23% combined. There were no intraoperative deaths, no complete spinal cord injuries, 4 partial spinal cord injuries (0.9%), 6 deep infections (1.3%) and 14 implant revisions (3.1%).

Conclusion: The initial clinical results from the British Spinal Registry support the hypothesis that such registries can produce useful audit data. There is no other record nationally of number and type of procedures in spinal surgery in the UK. The complication rates are similar to those reported elsewhere and provide an opportunity for benchmarking and for comparative personal and centre audit. The uptake and usage rates however are low and would not allow scientifically valid clinical results to be reported.

Introduction: Adolescent idiopathic scoliosis (AIS) is described as a sex-influenced autosomal dominantly inherited disorder with females more often affected than males, and operative ratio of 7F:1M (Child et al. 1999). Two AIS loci have been reported on chromosome 17p11 (Salehi et al. 2002) and chromosome 19p13.3 (Chan et al. 2002) in the Italian and Chinese populations, respectively. Three other susceptibility AIS loci on chromosome 6q, distal 10q and 18q (Wise et al. 2000), and more recently primary candidate regions on chromosomes 6, 9, 16, and 17 (Miller et al, 2005) have also been reported.

Purpose: o perform a genome scan for suitable UK multiplex families and identify new genetic loci for AIS.

Method: NA samples from 208 subjects (134 affected, 17 reduced penetrance members and 79 normal) from 25 multi-generation British families with confirmed diagnosis of AIS were selected from our AIS family database, and genotyped for 410 polymorphic markers from the entire genome, spaced at 10 cM intervals. Genotypic data were exported into Cyrillic to construct the most likely inherited haplotypes for each chromosome and in each family. Two–point LOD scores were calculated using MLINK initially for the entire genotypic data, and again for the affected meioses only, followed by GENEHUNTER for multipoint linkage analysis for each family.

Results: Overall, 170 560 genotypes were obtained and analysed. DNA samples from 250 subjects from the 25 families are currently available for further genotyping and saturation mapping. Our AIS families show absence of linkage to the X chromosome as well as previously reported AIS loci, except for chromosome 9q and 17q as reported by Miller et al. (2005). Preliminary inspection of inherited haplotypes indicates that a number of these families may be segregating with several new AIS loci with LOD scores ranging from 1.0 – 3.63 for various DNA markers on 15 different chromosomes. Linkage evaluation and comprehensive saturation mapping of the two loci with the highest LOD scores of 3.63 and 4.08 for chromosomes 9q and 17q respectively were conducted and these regions were successfully refined. Candidate genes are currently being screened.

Conclusion: Preliminary evidence already indicates genetic heterogeneity of AIS. Candidate genes from the highest LOD score regions are at present being screened.

Purpose: To perform a genome scan for suitable UK multiplex families and identify new genetic loci for AIS.

Method: DNA samples from 208 subjects (134 affected, 17 reduced penetrance members and 79 normal) from 25 multi-generation British families with confirmed diagnosis of AIS were selected from our AIS family database, and genotyped for 410 polymorphic markers from the entire genome, spaced at 10 cM intervals. Genotypic data were exported into Cyrillic to construct the most likely inherited haplotypes for each chromosome and in each family. Two–point LOD scores were calculated using MLINK initially for the entire genotypic data, and again for the affected meioses only, followed by GENEHUNTER for multipoint linkage analysis for each family.

Results: Overall, 170,560 genotypes were obtained and analysed. DNA samples from 250 subjects from the 25 families are currently available for further genotyping and saturation mapping. Preliminary inspection of inherited haplotypes indicates that a number of these families may be segregating with several new AIS loci with LOD scores ranging from 1.0 – 3.6 for various DNA markers on 15 different chromosomes (1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 13, 16, 17, 20, 21), and absence of linkage to the X chromosome. Linkage evaluation and comprehensive saturation mapping of the 2 loci with the highest LOD scores were conducted and these regions were successfully refined. Candidate genes are currently being screened.

Conclusion: Preliminary evidence already indicates genetic heterogeneity of AIS. Candidate genes from the two highest LOD score loci are at present being screened.

Aim: To compare thoracic scoliosis correction using either pedicle hooks or pedicle screws.

Methods and results: Two patient groups were studied. Data was collected prospectively and this is a review of the radiological data. All patients had structural thoracic scoliosis. Group 1, 14 patients (9 female and 5 male) mean age 14.6, were treated with posterior correction of scoliosis using the standard USS II technique using pedicle hooks and screws. Group 2, 14 patients (11 female and 3 male) mean age 15.3 were treated using pedicle screws alone to correct the apical deformity, using a variation of the original USS technique. Pre and postoperative Cobb angle, apical vertebral rotation (AVR, Perdriolle method) and apical vertebral translation (AVT) were measured.

Unpaired “t” test was used to compare the magnitude of correction in both groups. The mean follow up period was 6.7 months (range:3–18).

The mean corrections of Cobb angle, AVR and AVT, in group I were 61.1% (range:48.5–83.9), 33.3% (range:8.6–100) and 62.9% (range:43.2–91.4), respectively. In Group 2 the corrections were: 57.4% (range:21.4–81.7), 57.2% (range:16.7–100) and 58.7% (range:34–80.9).

There is no statistically significant difference between the correction of Cobb angle or AVT in both groups (P=0.479 and 0.443 respectively). However, the pedicle screws proved to be more effective at correcting the AVR (P= 0.017). No complications occurred and correction has been well maintained.

Conclusion: Pedicle screws can safely and effectively replace the pedicle hooks in the classical USS technique. They are more effective at correcting the rotational deformity, although do not provide a better correction of Cobb angle. These technical results now need to be correlated with relevant clinical outcomes.

Introduction: AIS is described as a sex-influenced auto-somal dominantly inherited disorder with females more often affected than males (operative ratio 7F:1M) 1. Two AIS loci have been reported on chromosomes 17p112 and 19p13.33 in the Italian and Chinese populations, respectively. Other susceptibility AIS loci on chromosomes 6p, distal 10q and 18p4, and more recently to chromosomes 6, 9, 16, and 175, and 19p136 have also been reported, in the American population.

Purpose: To perform a genome scan for suitable UK multi-generation families and identify new genetic loci for AIS.

Method: DNA samples from 208 subjects (116 affected members) from 25 British families with confirmed diagnosis of AIS were selected from our family database, and genotyped for 410 polymorphic markers from the entire genome, spaced at ~10 cM intervals. Using Cyrillic, most likely inherited haplotypes were constructed for each chromosome and family. Statistical analyses were calculated using MLINK and GENEHUNTER, initially for the entire genotypic data, and again for affected meioses only.

Results: 170,560 genotypes were obtained and analysed. Our AIS families show no linkage to the X chromosome. Preliminary inspection of inherited haplotypes indicates a number of families may be segregating with several new AIS loci with LOD scores from 1.0–3.64 for markers on 15 different chromosomes. Linkage analysis and saturation mapping of the 2 highest LOD score regions on chromosomes 9q34 and 17q25 were conducted. These regions were successfully refined and candidate genes are being screened.

Conclusion: Preliminary evidence already indicates genetic heterogeneity of AIS. Candidate genes from the two highest LOD score loci are at present being screened.

Objective: To investigate the reflex control of the internal oblique (IO) muscles

Design: Reflex activity in the IO muscles was evoked by (i) tapping each IO muscle in turn and (ii) tapping the abdomen in the midline to produce a stretch of equal magnitude in both muscles. Muscle activity was recorded using surface EMG.

Subjects: Seventeen asymptomatic subjects and one subject with scoliosis.

Outcome measures: Onset latency and normalised amplitude of reflexes

Results: Tapping the IO muscle on one side evoked large reflex responses in both ipsilateral and contralateral IO muscles. Across all subjects the reflexes in these two muscles were of equal amplitude (p=0.12). Measurements of onset latency suggest that both reflexes are monosynaptic in origin. Tapping in the midline also produced large amplitude responses. In two subjects, the response in one IO muscle was always larger than the other, irrespective of which of the three points was tapped, and this was repeatable. One of these subjects has a scoliosis.

Conclusions: The IO muscle is usually controlled from ipsilateral and contralateral muscle afferents. In a scoliotic subject this afferent activity was biased to the IO muscle on one side, and may therefore be associated with this condition

We compared magnetic resonance imaging (MRI) scans and plain antero-posterior (AP) and lateral radiographs of 100 randomly selected patients in order to detect segmental abnormalities of the lumbar spine. We started by identifying those who appeared to have a segmental defect of the lumbar spine on MRI scan. We then checked all 100 plain radiographs to detect the true rate of segmental abnormality. We detected 17 patients with a segmental abnormality that correlates well with other studies. We believe that MRI scanning alone is not sufficient to detect reliably all segmentation defects in the lumbar spine, and that a plain lateral and an AP x-ray is also required. Of those who do have a segmentation disorder we have identified a sub-group who are at risk of surgery at the wrong level, if the correct pre-operative work-up is not performed. The difficulty will occur when a segmental abnormality is present (as determined by plain radiographs) and it is missed by MRI scan, and plain films are not taken, and the correct level is determined by counting upwards from the lumbosacral take-off angle using the image intensifier in theatre. We believe that all patients undergoing nerve root decompression should have an AP and lateral plain film and an MRI scan as well as pre-operative image intensification in theatre. Although the number of patients that would be affected by this is small, the consequences of operating on the wrong level are well recognised and can be avoided by being aware of the potential problem and by adhering to the above recommendations.

Objective: To evaluate a new system of prescribing and administering IV morphine introduced by our Paediatric Pain Service for paediatric patients undergoing corrective spinal surgery.

Design: An audit of post-operative pain management was conducted retrospectively on patients who had undergone scoliosis correction between November 1999 and September 2001.

Subjects: Sixteen patients between the ages of nine and seventeen years who had undergone spinal scoliosis correction during the study period were evaluated.

Outcome measures: The average post-operative IV morphine consumption, the pain and sedation scores, the incidence of side effects, and the use of adjuvant analgesics were analysed. Statistical evaluation was carried out using the Student’s T test and the Mann-Whitney U test.

Results: Morphine consumption was significantly higher in the first post-operative twenty-four hour period, as well as in the over 13 year-old age group. There was no significant difference in morphine consumption between genders or ASA physical status. The pain scores were significantly higher in males compared to females on day one post-operatively. There was no statistical difference in sedation scores.

Conclusions: An audit of the post-operative pain regimen for patients undergoing spinal scoliosis correction provided by the Paediatric Pain Management Service has shown that it is both efficient and safe. We recommend an anticipated pain management pathway of recovery following spinal fusion for idiopathic adolescent scoliosis.