Background

Work disability due to low back pain (LBP) is a global concern, resulting in significant healthcare costs and welfare payments. In recognition of this, recent UK policy calls for healthcare to become more ‘work-focused’. However, an ‘evidence-policy’ gap has been identified, resulting in uncertainty about how this is to be achieved. Clear, evidence-based recommendations relevant to both policy-makers and healthcare practitioners are required.

Introduction purpose and background

Implicit in the diagnosis of CES is the presence of leg pain with a spectrum of bladder and/or bowel disturbance and/or peri-anal sensory loss. Current research describes the clinical features of patients with radiologically confirmed CES, but the specificity of these features is not known. This study explores the accuracy of patient self reported bladder or bowel dysfunction and numbness of the bottom in individuals presenting with lumbar nerve root pain.

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that the initial assessment focuses on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One of these red flags is the first presentation of LBP in people over the age of 55 years. The aim of this study was to investigate the incidence of serious spinal pathologies in patients presenting with new onset of LBP over the age of 55 years.

Method/Results: This was a prospective analysis of all patients presenting to a secondary care spinal triage service over a 3 year period (2005–2008). During the study period, in excess of 3000 patients were seen. Of these, a total of 70 patients presented with a first onset of LBP aged over 55 years and had no other red flags. Analysis of this group of patients revealed 2 serious spinal pathologies. Both of which were osteoporotic vertebral compression fractures. Both patients were over age 75. In addition 1 patient had severe central lumbar canal stenosis. Therefore, 2.3% of patients presented with the first onset of LBP > 55 years, of which 2.9% has serious pathology. Patients > 55 years with cancer or infection had other red flags in addition.

Conclusion: In isolation the first onset of LBP over the age > 55 accounts for a small percentage of this secondary care population, of which 2.9% had vertebral compression fractures. Further research into the clinical value of this independent red flag or its added value in combination with other red flags is recommended.

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that initial assessment should focus on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One flag is the presentation of back pain in people under the age of 20. LBP in children is common, with an annual and lifetime prevalence of around 30%. Because many cases of benign and malignant spinal tumours and spinal infection have been documented in this age group, young people with LBP who are referred to secondary care are investigated by MRI.

Purpose: The purpose of this study is to review the incidence of tumour and infection in subjects under age 20, who present to secondary care with LBP, but do not have concerning objective findings such as neurology, fever, acute deformity or scoliosis.

Method/Results: A retrospective analysis of the MRI database, at a specialist orthopaedic hospital, from 1994 until 2005 identified 403 limited MRI’s taken in LBP patients under the age of 20. Analysis revealed 2 radiological reports of spinal tumour, 1 ependymoma and 1 osteoid osteoma and no cases of spinal infection. Histology confirmed pathology in the ependymoma but excluded serious pathology in the osteoid oste-oma. Other MRI findings, included minor degenerative change (17%), pars defect (9%) and disc prolapse (4%). Therefore, over an 11 year period only 0.25% of young people with LBP who underwent limited MRI were found to have serious pathology.

Conclusion: In conclusion, LBP is relatively common in people under the age of 20 and can be severe enough to warrant secondary care referral. However, in the absence of other objective findings, serious pathologies such as cancer and infection remain rare. These results support the use of limited MRI for screening. However, further research into the clinical value of “under 20” as an independent red flag is recommended.

Background and Purpose: There is evidence that biospychosocial information imparted to patients can be effective in reducing pain, increasing function, shifting unhelpful beliefs, and reducing healthcare utilization. The effectiveness of this information is enhanced if it is addresses the individuals concerns. Qualitative studies have identified common patient concerns, but these studies have typically been small sample sizes. The purpose of this study is to identify FAQ’s of patients presenting to secondary care in the UK, and to explore differences with regard to diagnostic category, disability, employment status and level of distress.

Methods: In excess of 500 consecutive new patients presenting to secondary care, for a specialist opinion were invited to write up to 3 questions which they would like answered in their consultation that day. In addition patients completed the battery of questionnaires normally used in these clinics (VAS (pain), ODI HAD, employment status). Post consultation each patient was assigned to a diagnostic category including non-specific LBP.

Themes from the questions were identified and discussed by two of the authors (blind to each other) using the first 50 questionnaires. The most frequently asked questions were then identified for the whole group and for subgroups determined by diagnosis, disability, employment status and distress and age.

Results: Although the most FAQ’s have been identified, there were differences between subgroups and the range of questions was large. The key themes and relationships identified will be presented.

Conclusion: Although addressing FAQ’s in patient information is to be encouraged. The findings of this study emphasize the importance of exploring and addressing individual patient concerns.

Study Design: Prospective cohort study

Objective: To assess the ‘red flag’ symptom of night pain as an indicator for serious disease in patients attending a back pain triage clinic (BPTC).

Summary of Background Data: Although common in patients with known serious pathology, the prevalence of night pain in this population is not known.

Methods: 482 consecutive patients attending BPTC were assessed (including history of frequency and duration of night pain). Clinical examination was performed and demographic data obtained. MRI was performed if indicated according to local guidelines.

Outcome measures: Oswestry (ODI), Visual Analogue Scales (for pain, distress and coping) and Hospital Anxiety Depression (HAD) patient based outcome scores were obtained. Serious pathology was defined as infection or tumour as per AHCPR Guidelines (1994) which state that these symptoms are associated with severe night time pain.

Results: 213 patients had night pain with 90 having pain every night. No serious pathology was identified. Patients with night pain had 4.95 hours continuous sleep (2–7) and were woken 2.5 times/night (0–6). Patients with pain every night exhibited higher ODI and HAD scores than those that did not.

Conclusions: Although it is a significant and disruptive symptom for patients, these results challenge the sensitivity of the presence of night pain per se as a useful diagnostic indicator for serious spinal pathology in a back pain triage clinic.

Acute recurrent LBP is prevalent within western society and is recognised as a predictor of chronic LBP related disability. Despite this, predictors of disability, in subjects with acute recurrent LBP, have not yet been explored. This study aimed to examine the association between variables of pain, psychology and disability, in acute recurrent LBP, and establish which of these measures best predicts LBP related disability.

The study was of prospective design employing regression analysis. A battery of questionnaires and a series of functional tests were obtained from 47 subjects, with acute recurrent LBP, at assessment and on conclusion of treatment. Measures of pain (VAS), psychology (CSQ, TSK, MSPQ, ZDS) and disability (step ups, stand ups, walking test, RMDQ) were employed. The criterion measure for resultant disability was the Roland Morris Disability Questionnaire.

The characteristics of the sample were found to typify that of an acute, rather than chronic, LBP population. Pain was found to correlate with all other variables and a relationship was demonstrated between subjective disability and psychological variables. The relationship between psychological variables and objective disability however, was less clear. Forty four percent of the residual disability was explained by initial scores of the Visual Analogue Pain Scale, the Modified Somatic Perceptions Questionnaire and the Roland Morris Disability Questionnaire. Fifty six percent of the resultant disability remains unexplained by the variables explored in this study.

It was concluded that subjects at risk of chronic LBP related disability might be identified at assessment by the initial levels of , anxiety and subjective disability.