Aim: The aim is to assess the accuracy of post-contrast imaging in identifying recurrent disc prolapse (RDP).

Material and methods: 246 revision discectomies performed between January 1994 and June 2004 were considered. Of these, for 192 LIRDs, post-contrast scans (95 CTs and 97 MRIs) within 6 months of operation, and adequate operation records were available. Original scan reports and scan interpretation of an independent observer were taken into account.

Results: Of 95 post-contrast CTs, 88 showed RDP (29 large-contained, 12 large-sequestrated, 39 moderate-contained, and 8 small-contained), 2 hypertrophic epidural scar (HES), and 5 lateral recess stenosis but no RDP or HES. From operation records, 30 of these 88 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 21 of 29 large-contained (72.4%), 10 of 12 large-sequestrated (83.3%), 16 of 39 moderate-contained (41%) and 2 of 8 small-contained (25%). Of the 5 which did not show RDP, 2 (40%) were found to have RDP (1 moderate-contained and 1 large-contained) during operation.

Of 97 post-contrast MRIs, 85 showed RDP (18 large-contained, 22 large-sequestrated, 26 moderate-contained,4 moderate-sequestrated,13 small-contained, and 2 small-sequestrated), 5 HES, and 7 lateral recess stenosis but no RDP or HES. From operation records, 31 of these 85 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 10 of 18 large-contained (55.6%), 19 of 22 large-sequestrated (86.4%), 8 of 26 moderate-contained (30.8%), 4 of 4 moderate-sequestrated (100%), 6 of 13 small-contained (46.2%) and 1 of 2 small-sequestrated (50%). Of the 7 which did not show RDP, 1 (14.3%) was found to have moderate-contained RDP during operation.

Conclusion: Accuracy of post-contrast scans is proportional to the size of RDP. MRI has high accuracy for sequestrated RDP.

Aim: The aim is to correlate intra-operative findings such as epidural fibrosis (EF), size and type of disc fragment, lateral recess stenosis and dural tear with postoperative residual radiculopathy (RR) and residual low back pain (RLBP).

Material and Methods: 246 revision discectomies performed between January 1994 and June 2004 were considered, of which adequate records were available for 215 (201 ipsilateral and 14 contralateral). Of 201 LIRDs, 85 were at L5S1, 101 at L45, 10 at L5S1+L45, 3 at L34 and 2 at L23 level. Patients who had had fusion or instrumentation in addition to LIRD were excluded. For 201 LIRDs average follow-up was 18.5 months (range −1 to 96 months) and 100 LIRDs had a minimum of 12 months’ follow-up.

Results: Of the 179 first-time LIRDs, 65 (36.3%) had significant RR, 73 (40.8%) significant RLBP, 3 (1.7%) cauda equina syndrome, 2 (1.1%) infective discitis, and 1 (0.6%) foot-drop. Of the 21 second-time LIRDs, 15 (71.4%) had significant RR, 17 (81%) significant RLBP, 2 (9.5%) infective discitis and 1 (4.8%) cauda equina syndrome. EF was classified as abundant, moderate and scant. Incidence of RR and RLBP was proportional to amount of EF and size of hypertrophic scarred ‘disc’ bulge, but it correlated poorly with size of ‘soft’ disc prolapse. Lateral recess decompression in addition to LIRD did not significantly alter the incidence of RR and RLBP.

25 (12.4%) patients who had dural tear had worse results.

Conclusions: Large proportion of LIRDs result in significant residual symptoms. Second-time LIRDs have higher complication rates and even poorer outcomes.

Introduction: Referrals for Low Back Pain (LBP) are common and many patients appear to see more than one specialist. In one acute trust, a dedicated Spinal Assessment Clinic (SAC) run by nurse practitioners was developed.

Objective: To determine patterns of referral for LBP from primary to secondary care.

Method: All new referrals to the hospital for LBP in an index period June–November 1998 were included. Consultations for these patients in the preceding six months and the subsequent two years were studied.

Results: A total of 801 patients were referred in the audit period. The patients were seen in the SAC 75%, orthopaedics 5.5%, rheumatology 4.5%, neurosurgery 12% and the pain clinic 4%. Onward referrals made after the initial appointment from the SAC 4.9%, from orthopaedics 26.7%, from rheumatology 8.6%, from neurosurgery 33.7% and from the pain clinic 10.3%. Subsequent repeat referrals made by the GP occurred in 3.7%of patients initially seen in the SAC, 11.1% from orthopaedics, 2.9% from Rheumatology, 3.2% from Neurosurgery and 17.2% from the pain clinic. The average wait in days for a first appointment was SAC 42, orthopaedics 103, Rheumatology 82, Neurosurgery 78 and pain clinic 77.

Conclusion: The SAC offers a shorter wait for patients and an extremely low “churn” rate, implying high rates of satisfaction in patients and GP’s. The wait for other specialities is longer, and in orthopaedics and neurosurgery the re-referral rate is almost one third. Referral procedures to secondary care might need to be streamlined for more efficiency.

Introduction: the NHS places emphasis on outcomes and patient partnerships but measuring these factors is problematic. In 2003 the Spinal Assessment Clinic (SAC) moved from an old style hospital to a new PFI building providing an opportunity to audit the influence of environment on operational activity.

Objective: Does environment influence satisfaction with care and objective outcome in patients with LBP?

Method: Patients attending the SAC two months prior to relocation and two months following completed a Low Back Outcome Score (LBOS) and a satisfaction survey.

Results: The analysis of the satisfaction surveys demonstrated that the patients did not perceive any real difference in the two locations despite the significant age difference, layout and internal standards of the buildings.

The satisfaction of patients at both sites was analysed using a number of factors- the care provided was 79% before the move and 82% afterwards, their understanding of a nurse led service was rated as 73% and 85% respectively. Evaluation of the quality of information demonstrated that their questions had been answered well 78% and 75% respectively and the confidence and trust in the person providing the care was 91% and 89%.

Failure by the IT department in delivering effective links to hospital computer system resulted in the LBOS data not being completed in the period following the move with logistical difficulties in clinic organisation.

Conclusion: despite the difficulty of moving and problems encountered by staff from the SAC the patient did not perceive any alteration in quality.

Objective: Syrinx formation is estimated to occur in 20–25% patients after spinal cord injury. Aim of this study was to analyse the factors affecting the formation of post-traumatic syrinx.

Design: Retrospective study of 295 patients with spinal cord injury treated in a spinal injury centre with a minimum follow-up of two years since injury. Patient notes, x-rays and scans were reviewed.

Subjects: Two hundred and fifty-two men and 43 women were included in the study. The spinal injury was treated non-operatively in 172 (M 144, F28) patients and surgically in 123 (M 108, F 15) patients. Average age at the time of injury was 28.2 years. Mean follow-up was 6.4 years (2–34). There were 98 cervical, 134 thoracic and 73 lumbar and thoracolumbar injuries.

Outcome Measures: The incidence of post-traumatic syrinx in both groups and its relationship with level and type of skeletal injury, severity of spinal cord injury, sagittal angle at the injury level were assessed.

Results: In total 59 (20%) patients were identified with post-traumatic syrinx. Of the 123 patients managed operatively 15 (12.2%) had syrinx as did 44 (25.6%) of the 172 patients treated conservatively (p=0.001). Twenty-one (21.4%) cervical injuries, 29 (21.6%) thoracic injuries and nine (12.3%) lumbar injuries were found to have syrinx (p=0.023). Twenty-seven (46%) patients with syrinx had complete cord injury as did 130 (55%) patients who did not have syrinx (p=0.112). Fracture-dislocation was the injury most commonly associated with post-traumatic syrinx. Of the 40 `patients who had fracture dislocation as original injury, syrinx developed in 16 (40%). Eleven of the 18 patients with conservatively managed fracture dislocation, developed syrinx, compared to five of the 32 operatively treated fracture dislocations (p=0.0001). The mean sagittal angle at the level of injury was 25.2° in those syrinx formation, 20.4° in the conservatively treated patients without syrinx (p=0.1191) and 15.32° in the surgically treated patients without syrinx (p=0.016).

Conclusions: In a series of 295 patients, post-traumatic syrinx formation was found in 20% cases. It was significantly more common in patients treated conservatively, especially if the original injury was fracture dislocation. Syrinx formation was also significantly more common in cervical and thoracic cord injuries, but had no association with the completeness of cord injury. In the sagittal plane there was significantly more kyphotic deformity in those with syrinx formation.

Introduction: Numerous studies have reported the usefulness of exercise and increases in fitness in the management of Lower Back Pain (LBP). Additionally, the importance of psychosocial factors in both the development and chronicity of LBP have been reported. This study was designed to work within the local community and improve levels of health and awareness regarding LBP. More specifically an evaluation of how an educational package may influence fitness and exercise levels, disability and beliefs about LBP was undertaken.

Methods: 195 particpants were recruited from the community. Testing is conducted at 0, 12 and 24 months. Each participant completes a battery of tests including an aerobic fitness test and self-report questionnaires measuring disability (Low Back Outcome Score: LBOS), Acute pain (visual analogue scale), LBP history (time off work), and back pain beliefs (Back Beliefs Questionnaire: BBQ). participants receive a one to one educational intervention supported by educational literature (Back Book, exercise sheet and diary).

Results: BBQ scores improved significantly ( p = .000) between 0 and 12 months. This difference remained when controlling for gender, LBP history and acute pain level. No significant differences were found in LBOS scores and fitness levels. Significant differences existed between level of pain and LBOS scores, with higher pain resulting in lower LBOS values ( p = .000). A non-significant trend was observed between BBQ scores and higher pain levels, with higher pain resulting in smaller BBQ improvements.

Conclusions: Participants taking part in this research had significantly more positive beliefs about the inevitability of their future in relation to LBP after receiving an educational intervention. Anecdotal evidence from participants suggests the educational package was of benefit due to an improvement in their level of back care understanding. The study was unable to elicit any positive changes in fitness level or disability, although baseline fitness levels were above average, and disability scores, low.

Introduction: A Health Action Zone project has been designed to assess the effect of a public education programme to improve the community awareness of the correct approach to low back pain. As part of this project a preliminary survey of the public has been undertaken.

Methods: 195 members of the public were surveyed using by a number of members of the team using a pro-forma. Interview sites were selected to provide a cross section of the population of the community. Demographic details were collected together with data related to low back pain prevalence and attitudes to self management.

Discussion: The initial survey shows that people take too much rest and do too little exercise. The HAZ projects, which have been in existence for three years, have had small penetrance into the community. The Teesside Back Pain Partnership so far has focussed on individual education as part of other strategies. A radio, bus posters, leaf ets and posters campaign aimed at changing beliefs on back pain management. the pattern of behaviour is planned. The extremely low level of awareness of the TBPP will provide an opportunity to measure how much of any change may be attributed to this campaign.

Statement of Purpose: To enable GP’s and nurse practitioners to refer quickly, appropriately and effectively, at the first diagnosis of lower back pain.

Methods and result: Patients at the clinic, who were assessed and diagnosed by a GP/Nurse Practitioner, were asked to fill in an electronic questionnaire. The results of these were passed into a database where they could be accessed by an expert system program. This system used rule based logic and data mining concepts to assess the questionnaire answers, and presented a diagnosis of the patient. To determine system accuracy diagnoses were compared with actual diagnoses from the GP/Nurse Practitioner.

Conclusion: This project has been beset by several problems. The first being that a lack of patients with certain diagnoses has meant that it has been impossible to test the system with the more rare back problems.

The system accuracy is too low for the system to currently be of any use. This project is ongoing, the accuracy has improved significantly over the past year and we expect the improvement to continue next year. However, we have identified some problems in improving the accuracy. It has been noticed that there is a certain apathy present in some patients completing the questionnaires, resulting in less than accurate answers. Also the system can only produce one diagnosis. Patients with two back problems will get an incorrect diagnosis from the system.

Background: Many outcome measures for the assessment of low back pain (LBP) have been described but few are specific or objective. Electromyography of the lumbar paraspinal muscles (EMG) has been studied for some years now but has been used only as a research tool, not clinically. Using maximum voluntary contraction (MVC) is convenient but this introduces subject volition and may reduce inter-subject comparability.

Methods: 491 subjects were tested. 209 were LBP subjects with 282 normal controls. For each the MVC was measured. EMG studies were performed only at 2/3 MVC in 367 subjects and a further 34 subjects were studied at a range of loads between 10% and 100% MVC. Loads were expressed as a proportion of the subjects lean body mass (LBM.)

Results: There were highly significant differences in MVC and load as a proportion of LBM between back pain subjects and controls. More than one in five back pain subjects were unable to manage loads of 0.5 LBM compared to 0.4% of controls. Less than 40% of back pain subjects could manage 1 LBM compared to almost 75% of normal subjects.

EMG variables were significantly influenced by load. For a 1LMB change in load most variables changed by at least 100%, notable exceptions being Half Width (27%) and Initial Median Frequency (IMF)(4%).

The ability of EMG variables to discriminate between normals and back pain subjects was examined in groups 0.1LBM wide. There were significant differences in Half Widths between the normal and back pain subjects in most groups, independent of load. There were no significant differences in Median Frequency Slopes (MFSlope) of normal and back pain subjects except at between loads of 1.4 to 1.5 LBM (p< 0.05). Accuracy of discrimination was poor, seldom better than 0.6 until subjects were tested at loads above1.2 LBM when accuracy increased sharply to 0.95 at loads between 1.4 to 1.5 LBM.

Conclusion: The usefulness of MFSlope as a discriminator has been variably reported in the literature. The present data indicate that in experimental conditions with subjects able to achieve loads greater than 1 LBM it is useful. However this load is not achievable in patients presenting clinically, and the Half Width, which is robust and reliable at low loads may be more valuable in the clinical setting.

Objective: To assess the result of surgical stabilisation of spine in Spinal cord injured patients.

Design: Retrospective review of patients managed and followed at a spinal injury centre.

Subjects: Sixty-six patients with spinal cord injury, treated with surgical stabilisation of their spinal fracture and followed for a minimum of two years.

Outcome Measures: Delay in starting ambulation from injury/surgery, sagittal balance, metalwork failure and surgical complications.

Results: The mean age was 29.5 years (17–67), and five patients were female. The median follow up was 7.9 years (2–24). There were 19 cervical, 21 thoracic and 28 thoracolumbar and lumbar fractures. A total of 36 patients had over six weeks delay in starting ambulation. Of these 11 were due to inadequate fixation. Ten patients (50%) with cervical fracture and seven patients (25%) with lumbar fractures had normal lordosis. Significantly more patients with anterior cervical fixation had normal lordosis compared to those with posterior fixation. Nineteen with thoracic fracture had thoracic kyphosis within 40°. Nine patients had failure of metalwork. Surgical complications occurred in 21 (33%) patients.

Conclusion: Early ambulation was not achieved in the majority. The maintenance of lordosis was successful in cervical but not in lumbar spine. Posterior fixation of thoracic spine was successful in maintaining normal sagittal balance.