To quantify the expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery with one third of Specialist Spinal Surgeons due to retire in the next 3 years and to provide the needed expansion of 25% in the existing number of 175 surgeons.

A postal survey of the 528 SpRs was performed with a response rate of 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty nine percent indicated that they intended to avoid all Spinal Surgery. Thirty five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only 9 (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first 2 years of training, to 70% in the middle 2 years, and to 75% in the final 2 years and post CCST fellowships. Based on a projection of the 4. 3% response intending to become Specialist Spinal Surgeons there will be a shortfall of 34 Specialist Spinal Surgeons by 2005.

The features of Spinal Surgery which appear to have a negative affect and overwhelm the potentially attractive features are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to spinal surgery during SpR training.

The modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and a need for Spinal Surgeons to be encouraging and enthusiastic about this field of surgery are essential.

Objectives: To surgery the UK Specialist Orthopaedic Registrars (SpRs) to assess their perceptions of and attitudes towards spinal surgery, and to identify factors discouraging interest in spinal surgery.

Introduction: In order to improve the provision of spinal surgery in the UK, the existing 175 Orthopaedic Surgeons with an interest in Spinal Surgery needs to increase by 25%. There is a predicted shortfall in the number of orthopaedic trainees intending to practise spinal surgery.

Methods: A postal questionnaire was sent to all 578 SpRs

Results: Three hundred and seventy-four replied (71%). Sixty-nine percent intend to avoid spinal surgery. Thirtyfive (9%) intend becoming either Specialist Spinal Surgeons or Surgeons with a Spinal interest. Their perceptions will be discussed; the intellectual challenge and opportunities for research are widely recognised but are outweighed by poor perceptions of outcomes of surgery, psychological complications, and of badly organised clinics. There is also inadequate exposure to spinal surgery during training.

Conclusions: Training in spinal surgery could be improved by exposure to spinal surgery at an earlier stage of training, and the development of more specialised units with properly structured spinal clinics to include triage systems to assess referrals and close liaison between the specialities required to treat these patients.

Aim: To investigate the use of the Graf Dynamic Stabilisation System for the treatment of multi-level discogenic pain associated with symptoms of ‘instability’.

Introduction: Indications for the use of the Graf Ligament system remain controversial. There is a small group of patients who present with severely disabling pain with failed conservative treatment, of discogenic origin at more than one level, and associated with symptoms of so-called ‘instability’ (acute pain related to position and movement), for whom treatment is extremely difficult.

Methods: Twenty-two consecutive adult patients of working age with this clinical picture, with discogenic pain at two or three levels confirmed by discography, were treated with the Graf Ligament System. They were prospectively studied, and reviewed by an independent assessor.

Results: At an average of three year follow up, 50% had good or excellent results including return to work, 18% fair, and 32% were no better. None were worse. Correlation with pre-operative MRI findings and complications will be discussed.

Conclusions: Whilst such dynamic systems may have a role in the treatment of discogenic pain, the success rate in this series does not justify its continued use for this indication without further research into the theoretical basis of the action of such dynamic stabilisation systems and the entry of all cases into prospective controlled trials.

Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of discogenic back pain after two years.

Introduction: Discography remains the main method to assess whether a degenerate disc is the source of back pain. The treatment of such discogenic pain is difficult. There is only one previous RCT of the use intradiscal steroids, but with a short follow-up.

Patients and Methods: 120 consecutive patients with positive discography were randomised intra-operatively to receive an intradiscal injection of saline or 40mgs Depomedrone. Outcome was assessed using a back pain questionnaire at six weeks, three and six months, and at two years. Pain (using a visual analogue score), disability (the Oswestry Disability Index), and psychological status (DRAM score) were measured. The results were correlated with Modic changes and high intensity zones on MRI scan.

Results: An initial improvement of back pain in the steroid group is not maintained at two years, with no statistical difference between the two groups. Correlation of the results with the MRI findings will be presented.

Conclusion: This study demonstrates the need for long-term follow-up of such intradiscal therapeutic methods of treating discogenic pain.

Our aim was to judge the influence of preoperative psychological disturbance on the outcome of lumbar discectomy. We evaluated 66 patients, before and after operation, using a self-administered questionnaire. Disability was assessed using the Oswestry disability index and psychological disturbance the Distress and Risk Assessment Method (DRAM) score. Patients were classified as normal, at risk or distressed, and the outcome of surgery in the three groups was compared at a follow-up of six months.

The mean self-reported preoperative disability was significantly higher in those with psychological disturbance. A total of 54 patients (82%) returned completed postoperative questionnaires. Postoperative disability scores at six months were not significantly different in the three risk groups. Psychological disturbance improved after surgery. Our study suggests that the early outcome of lumbar discectomy is not affected by preoperative psychological disturbance. We conclude that a patient with a symptomatic prolapsed intervertebral disc should not be denied surgery on the basis of preoperative psychological assessment.