Previous research has suggested that when subjected to painful lumbar stimulation, chronic low back pain (CLBP) patients with illness behaviour (IB) are unable to effectively engage a sensory modulation system utilised by patients without IB¹. Furthermore, reduced insular cortex volume in CLBP patients with IB, may compound this problem².

Pain Management Programs (PMP) has demonstrated reductions in IB and disability associated with chronic pain conditions. This current study aims to assess whether the pattern of cerebral response to pain in IB patients could be normalised by participation in a PMP.

12 patients with CLBP and IB (>4/5 Waddell signs present) were recruited prior to attending a 16-day PMP. FMRI scanning occurred prior to (PrePMP) and upon completion of the PMP (PostPMP). 8 healthy volunteers (HC) were scanned once.

As in previous research, painful stimuli consisted of intense electrical stimulation delivered bilaterally to the lower back. The presentation of 3 colours indicated the likelihood of receiving 10second stimulation to the lower back (Always, Never and Maybe).

IB scores were significantly reduced PostPMP (p <0.05). FMRI group activation maps for the Always condition revealed PostPMP patients increased activation in posterior regions, areas similarly activated by HC. For the Maybe condition, compared to PrePMP group, HC demonstrated greater activation in precuneus and middle and inferior frontal regions. Compared to their pre-treatment selves, PostPMP patients demonstrated increased activation in posterior and frontal regions.

The results demonstrate that completion of a 16-day PMP leads to alteration in the brain's response to painful low back stimulation in CLBP patients with IB. Increased activation is seen in regions associated with the top-down modulation of pain. The response is similar to that seen in HC, and greater than before PMP confirming that the PMP process facilitates the utilisation of more normal coping pathways in response to CLBP.

How much sway is significant for a traditional Romberg test has always been open to interpretation and debate. Prospective and detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a pro-prioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Introduction: There is still no standard approach to applying the Romberg test in clinical neurology and the criteria for and interpretation of an abnormal result continue to be debated.

Methods: Detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed prospectively. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Results: Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

Conclusion: The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a proprioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Ethics approval: none

Interest statement: none

The purpose of the study is to assess changes in cortical activity in chronic low back pain patients with and without illness behaviour.

Introduction: It is well recognised that patients with chronic low back pain (CLBP) may have major psychological factors which affect their level of disability. Abnormal patterns of illness behaviour have been described ¹.

Methodology: 30 patients with CLBP of more than six months duration were recruited. Patients with radicular pain or previous surgery were excluded. Two groups were created dependant on the presence of Waddell signs. “Copers” (n=16) showed 0 or 1 Waddell signs. “Non-copers” (n=14) showed 4 or 5 Waddell signs.

After informed consent, all subjects underwent fMRI scanning. Experimental pain was induced by thermal stimulation of the right hand. Straight leg raising (SLR) was performed following visual clues indicating that a leg raise was either definitely, possibly or not going to occur. Finally, clinical LBP was simulated by direct vibrotactile stimulation of the lumbar spine to a VAS threshold of 7/10.

The individual fMRI scans were independently referenced to anatomical markers and corrected for motion. Inter group analysis was performed using cluster-corrected thresholds of p< 0.05.

Results: During experimental pain stimulation, Non-copers showed significantly increased cortical activity as compared to Copers. Similar findings were evident when SLR was anticipated. The areas of increased cortical activity were primarily regions known to be involved in affective pain interpretation suggesting heightened activity.

When clinical LBP was simulated, the outcome was strikingly different with the Copers showing increased cortical activity particularly in the dorsolateral prefron-tal cortex and regions associated with cognitive pain processing and inhibition of subcortical pain pathways.

Discussion: This study shows that in patients with CLBP and illness behaviour cortical pain processing is abnormal. The findings suggest that possibly the abnormal behaviour shown by such patients may be due to failure of cognitive inhibitory pain pathways. It is possible that these abnormalities might respond to either pharmacological or psychological treatment.

Study Design: Retrospective case review.

Objective: To assess factors influencing functional outcome, recurrence and survival following surgery for intradural spinal tumours

Subjects: Between January 1994 and December 2001, 115 patients had surgery for intradural spinal tumours: 76 extramedullary (48 male, mean age 54 years): 39 intramedullary (22 male, mean age 44 years).

Outcome measures and analysis: Functional outcome: Frankel scale. Recurrence: new symptoms with tumour growth. Death: post-operative or disease progression. Univariate and multivariate analysis was performed to identify features predicting post-operative functionally useful Frankel scale (4–5), recurrence and survival.

Results: 64 extramedullary tumours were excised, 12 debulked. 21 intramedullary tumours were excised, 13 debulked, 5 biopsied. Commonest tumours: meningioma, schwannoma, ependymoma, astrocytoma. 14 intramedullary tumours received radiotherapy. Mean follow-up was 45 months (range 4–117 months). There were 12 recurrent tumours. There were 8 deaths (2 post-operative, 6 disease-progression). 23% had complications (CSF leak, meningitis, wound infection/dehiscence). Functionally 96% of extramedullary tumours were unchanged/improved, 82% of intramedullary tumours were unchanged/improved. Multivariate analysis demonstrated that recurrence (Odds Ratio 28.2; 95% Confidence Interval 2.3–342.4) was the only significant factor influencing survival for intramedullary tumours. No factors investigated predicted functional outcome or recurrence in intramedullary tumours. No factors predicted any outcome in extramedullary tumours.

Conclusions: Our results were comparable to other studies. The two cases of MRSA meningitis (one death, one paralysis) reflect the growing problem of MRSA in neurosurgical units. Recurrence predicted poor survival in intramedullary tumours.

Study Design: Retrospective case review

Summary of Background Data: The Chiari malformation is a condition characterised by herniation of the posterior fossa contents below the level of the foramen magnum.

Objectives: To present the long term outcome and complication rate following hindbrain decompression for this condition.

Methods: We retrospectively analysed the results of patients who underwent hind brain decompression between 1994 and 2003. There were 70 cases with a mean age of 32 years. Follow up was carried out with clinical examination and repeat MRI scans. The mean follow up was 4.7 years. Thirty-six patients had associated syringomyelia. Patients underwent hind brain decompression through a small posterior fossa craniectomy, opening of the foramen magnum with or without removal of arch of C1.

Results: One patient died and one had a stroke which resolved except for mild facial weakness. Long term follow up revealed that 50% of the patients were asymptomatic following surgery and another 26% had marked improvement in their symptoms. One patient deteriorated post-operatively and the remainder (23%) had unchanged condition. Of the patients presenting with scoliosis 67% had no further progression in their curve.

Conclusion: This is the largest series presented from a single centre with pre- and postoperative MRI fol1ow up. Our results compare favourably with previously published literature.

Introduction: Intradiscal electrothermal therapy (IDET) is a novel minimally invasive treatment for discogenic back pain. It involves inserting a catheter into discs which are suspected of being symptomatic in order to heat certain regions of the disc matrix and thereby influence the pain process. The clinical efficacy of IDET appears to be variable, and the scientific evidence suggests that the heating effect on disc tissues is very local to the catheter. We test the hypothesis that IDET can affect the internal mechanical functioning of lumbar intervertebral discs.

Methods: Eighteen cadaveric lumbar “motion segments” (aged 64–97 yrs) were used, 16 of which had degenerated intervertebral discs. Following incubation at 37°C, a miniature pressure transducer, side mounted in a 1.3mm diameter needle, was used to measure the distribution of compressive “stress” along the mid-sagittal diameter of each disc while it was compressed at 1.5 kN. Measurements were repeated in three simulated postures. IDET was then performed, using biplanar radiography to confirm placement of the heating element, and an independent thermocouple to measure temperature in the inner lateral annulus. Stress profilometry was repeated immediately after IDET.

Results: Peak temperatures in the inner lateral annulus during IDET averaged 40°C (STD 2.3°). Differences between stress measurements repeated before IDET never exceeded 8% (NS), and a sham IDET procedure produced no consistent changes. After IDET, pressure in the nucleus fell significantly by 6–13%, and stress peaks in the annulus were reduced (P< 0.008). In 12/18 specimens, annulus stress peaks were reduced by more than 8%, and in these “responders”, the mean reduction was 78%. Stress concentrations were increased by more than 8% in two specimens.

Conclusion: IDET has a significant but inconsistent affect on compressive stresses within intervertebral discs. These results may partly explain the variable clinical success of IDET.

Introduction: Intradiscal electrothermal therapy (IDET) is a novel treatment for discogenic back pain. A heating element is inserted percutaneously into a disc in order to denature the collagen of the posterior annulus. Clinical success is claimed, although laboratory studies indicate that temperature increases may be insufficient to cause widespread collagen denaturation, or denervation, and that IDET has little effect on gross mechanical properties. We report on changes in internal disc mechanics following IDET.

Methods: Ten cadaveric lumbar ‘motion segments’ (aged 72–79 yrs) were stored at −17°C. Subsequently, each was equilibrated at 37°C. A miniature pressure transducer was used to measure the distribution of compressive stress along the mid-sagittal diameter of each disc while it was compressed at 1.5kN. IDET was performed, using bi-planar radiography to confirm placement of the heating element, and an independent thermocouple to measure temperature in the inner lateral annulus. Stress profilometry was repeated irnmediately after IDET.

Results: Before IDET, all discs exhibited stress concentrations typical of mild degeneration. Accurate placement of the element was confirmed in all discs. Temperatures in the inner lateral annulus during IDET reached only 40.9°C (STD 2.3°C). Differences between stress measurements repeated before IDET never exceeded 8% (NS). After IDET, peak stresses (above nucleus pressure) were reduced by more than 8% in 6/10 specimens (mean reduction 55%), increased in 2/10, and were unchanged in 2/10. Nucleus pressure fell by 13% (n=10 0, P=0.05).

Discussion: IDET had a variable effect on these 10 degenerated discs. In six of them, stress concentrations in the annulus were reduced, suggesting that IDET can cause disc material to resist compression in a more coherent fashion, possibly by ‘bonding’ fragmented tissue together, and thereby distributing load more evenly across the endplate. Reduction in nucleus pressure following IDET suggests load transfer to the neural arch, although this could not be confirmed. Reducing annulus stress concentrations could conceivably reduce pain in some individuals.