Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

A statement of the purposes of the study and background:. Merely publishing clinical guidelines is insufficient to ensure their implementation in clinical practice. We aimed to clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. A summary of the methods used and the results:. We conducted semi-structured interviews with 53 purposively-sampled clinicians from south-west England. Participants were: 16 General Practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses. Thematic analysis showed that official guidelines comprised just one of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organisational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology - “non-specific LBP” - unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services and sparse commissioning of guideline-recommended treatments. A conclusion:. The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and commissioning guideline-recommended treatments for NHS patients

Background

Sciatica is common and associated with significant impacts for the individual, health care and society. The SCOPiC randomised controlled trial (RCT) is investigating whether stratified primary care for sciatica is more effective and cost-effective than usual, non-stratified primary care. Stratified care involves subgrouping patients to one of three groups based on a combination of prognostic and clinical indicators. Patients in one of these groups are ‘fast-tracked’ with an MRI scan to spinal specialist opinion. Our aim was to understand the perspectives of clinicians on the acceptability of this ‘fast-track’ pathway.

Background to the study:

The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. PROMs data are often collected using hard copy questionnaires. New technology enables electronic PROM data collection.

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Background and Purpose. The UK's NIHR and Australia's NHMRC have funded two randomised controlled trials (RCTs) to determine if lumbar fusion surgery (LFS) is more effective than best conservative care (BCC) for adults with persistent, severe low back pain (LBP) attributable to lumbar spine degeneration. We aimed to describe clinicians’ decision-making regarding suitability of patient cases for LFS or BCC and level of equipoise to randomise participants in the RCTs. Methods. Two online cross-sectional surveys distributed via UK and Australian professional networks to clinicians involved in LBP care, collected data on clinical discipline, practice setting and preferred care of five patient cases (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were also asked about willingness to randomise each patient case. Results. Of 174 responses (73 UK, 101 Australia), 70 were orthopaedic surgeons, 34 neurosurgeons, 65 allied health professionals (AHPs), 5 others. Most worked in public health services only (92% UK, 45% Australia), or a mix of public/private (36% Australia). Most respondents chose BCC as their first-choice management option for all five cases (81–93% UK, 83–91% Australia). For LFS, UK surgeons preferred TLIF (36.4%), whereas Australian surgeons preferred ALIF (54%). Willingness to randomise cases ranged from 37–60% (UK mean 50.7%), and 47–55% (Australian mean 51.9%); orthopaedic and neuro-surgeons were more willing than AHPs. Conclusion. Whilst BCC was preferred for all five patient cases, just over half of survey respondents in both the UK and Australia were willing to randomise cases to either LFS or BCC, indicating clinical equipoise (collective uncertainty) needed for RCT recruitment. Conflicts of interest. None. Sources of funding. No specific funding obtained for the surveys. DB, SA, AG and NEF have funding from the National Institute for Health Research (NIHR) UK (FORENSIC-UK NIHR134859); NEF, DB and SA have funding from the Australian National Health and Medical Research Council (NHMRC FORENSIC-Australia GA268233). AG has funding from Orthopaedic Research UK (combined with British Association of Spine Surgeons and British Scoliosis Society) and Innovate UK. NEF is funded through an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (ID: 2018182)

Aims. To benchmark the radiation dose to patients during the course of treatment for a spinal deformity. Methods. Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)). Results. There were more ionizing radiation-based imaging events and higher radiation dose exposures in the surgical group than in the non-surgical group (p < 0.001). The difference in effective dose for children between the surgical and non-surgical groups was statistically significant, the surgical group being significantly higher (p < 0.001). This led to a higher estimated risk of cancer induction for the surgical group (1:222 surgical vs 1:1,418 non-surgical). However, the dose difference for adults was not statistically different between the surgical and non-surgical groups. In all cases the effective dose received by all cohorts was significantly higher than that from exposure to natural background radiation. Conclusion. The treatment of spinal deformity is radiation-heavy. The dose exposure is several times higher when surgical treatment is undertaken. Clinicians should be aware of this and review their practices in order to reduce the radiation dose where possible. Cite this article: Bone Joint J 2021;103-B(4):1–7

Introduction. Yellow flags are psychosocial indicators which are associated with a greater likelihood of progression to persistent pain and disability and are referred to as obstacles to recovery. It is not known how effective clinicians are in detecting them. Our objective was to determine if clinicians were able to detect them in secondary care. Methods. 111 new referrals in a specialist spine clinic completed the Oswestry Disability Index (ODI) and a range of other validated questionnaires including the yellow flag questionnaire adapted from the psychosocial flags framework. Clinicians blinded to the patient data completed a standardized form to determine which and how many yellow flags they had identified. Results. The average number of yellow flags per patient was 5 (range: 0–9). Clinician sensitivity in detecting yellow flags was poor, identifying only 2 on average. The most common yellow flag reported by patients was fear of movement or injury (88%), and this was also the yellow flag most frequently missed by clinicians, being identified correctly in only 45% of patients. The most commonly misidentified was patient uncertainty, in 28% of patients. Patients who reported more yellow flags were more likely to score higher on their ODI (p<0.01), Modified somatic perception score (p<0.01) and Modified Zung Depression Index (p<0.01). They also had poorer Low Back Outcome Scores (LBOS) (p<0.01). Conclusion. Clinician sensitivity in detecting yellow flags is poor. Improved identification of obstacles to recovery may improve outcomes. Clinicians may improve detection of these obstacles by having a simple set of questions completed by the patient

Background and aims. The Keele STarT Back approach is effective for stratifying patients with low back pain in primary care, but a similar approach has not been tested with a broader range of patients with musculoskeletal (MSK) pain. We report a feasibility and pilot trial examining the feasibility of a future main trial of a primary care based, risk-stratification (STarT MSK) approach for patients with back, neck, knee, shoulder or multi-site pain. Methods. A pragmatic, two-parallel arm, cluster randomised controlled trial (RCT) in 8 GP practices (4 stratified care involving use of the Keele STarT MSK tool and matched treatment options: 4 usual care). Following screening, adults with one of the five most common MSK pain presentations were invited to take part in data collection over 6 months. Feasibility outcomes included exploration of selection bias, recruitment and follow-up rates, clinician engagement with using the Keele STarT MSK tool and matching patients to treatments. Results. 524 participants (231-stratified care, 293-usual care) were recruited (target n=500) over 7 months (target 3 months), with 15-withdrawals (5-intervention, 10-controls). Minimal selection bias was identified between participants/non-participants, or trial arms. The pain-intensity follow-up rate was 88%. Clinicians used the STarT MSK tool in 41% of relevant consultations (judged as ‘partial success’) and adhered to recommended matched treatments in 69% of cases (judged as ‘success’). Conclusions. A future main RCT is feasible, with some amendments in the wording of the tool and the matched treatment options, to determine the clinical and cost-effectiveness of stratified care versus usual care for patients with MSK pain. Conflicts of interest: ‘No conflicts of interest’. Sources of Funding: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1211-20010). Nadine Foster is a NIHR Senior Investigator and was supported through an NIHR Research Professorship (NIHR-RP-011-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care

Purpose. This research project explored the experiences, attitudes, beliefs, and perceptions of healthcare professionals (physiotherapists and orthopaedic surgeons) and people with chronic low back pain (CLBP) regarding the barriers and facilitators to activity normalisation following physiotherapy. Methods. A qualitative study of the perspectives of patients, physiotherapists and orthopaedic surgeons on CLBP was undertaken in Saudi Arabia. One focus group discussion was conducted with seven patients who had received physiotherapy for CLBP, along with one focus group discussion with eight physiotherapists and seven individual interviews with orthopaedic surgeons. The focus group discussions and interviews were transcribed and analysed using framework analysis. Results. We identified seven factors facilitating or hindering activity normalisation following physiotherapy: symptom control, patient education and awareness, adherence to treatment plan, psychosocial factors, role of the clinician, social support, and issues relating to the healthcare system. Conclusion. Clinicians stressed the importance of exercise and regular activity in spite of pain as an important factor hindering activity normalisation. Patients appreciated reassurance and advice from clinicians but also noted that conflicting and ambiguous advice and diagnosis was common. This may contribute to poor adherence with advice and exercise. Fear of pain and recurrence of injury were highlighted as important factors hindering activity normalisation, particularly since some patients did not take active steps to control pain. Finally, whilst multidisciplinary teams may support patient recovery and activity normalisation, this is often expensive and intensive and may be beyond the reach of a healthcare system without a properly functioning referral system and insufficient specialised clinics and physicians. Conflicts of interest: None. Sources of funding: This research was supported through a PhD scholarship from Prince Sattam bin Abdulaziz University, Saudi Arabia, at the University of Nottingham, United Kingdom

Purpose and Background:. Clinical interpretations of Degenerative Lumbar Disc Disease are not described in the literature. The purpose of this study was to establish a consensus of expert clinical opinion in order to fuel further research. Methods:. A reliable and valid electronic survey was designed to include theoretical constructs relating to training and education, general knowledge, assessment and management practices. Clinicians from the Society of Back Pain Research U.K. were invited to take part. Quantitative data was collated and coded using Bristol on-line survey software, and content analysis was used to systematically code and categorize qualitative data. Results:. Respondents represented a wide range of clinical specialties. The majority graduated in the U.K. (87%), were clinically active and had greater than 9 years postgraduate clinical experience (84%). MRI (36%) and physical assessment (21%) were cited as the most important clinical assessment tools. Reduction in disc height (92%) and disc dehydration (90%) were reported as the most important variables with respect to DLDD diagnosis. The most effective treatment approaches varied from education and reassurance, pain management, cognitive behavioural approaches to core stability training and group activity. Health professionals viewed the future of care advancement in terms of improvements in patient communication (35%) and education (38%). Treatment stratification (24%) and advancing evidence based management practices through research were also regarded as essential (27%). Conclusion:. Spinal clinical experts have clear views on DLDD assessment. In terms of management the results are varied suggesting inconsistency and uncertainty

Purpose. To measure the prevalence, type and instigator of verbal interruptions during initial consultations between clinicians and patients with low back pain. Background. During initial consultations, patients take on average, 92 seconds to outline their problem, if given the chance. Few achieve this, with clinicians interrupting (25–69% of cases) in as little as 12 seconds, either with an ‘overlap’, (a projection error of when a turn ends), or an ‘interruption’ (a start-up before the speaker's talk is complete). The prevalence and impact of these in back pain consultations is unknown. Methods:. Twenty-five clinical encounters (totalling 975 minutes) between physiotherapists in primary care and patients with back pain were observed, audio-recorded, transcribed verbatim and analysed. Data were managed using a Framework approach and the prevalence and reasons for overlaps and interruptions were determined. Results. This data set comprised 15,489 turns. Of the 7,659 patients' turns 17% were incomplete, with n=385 overlaps and n=284 interruptions by clinicians (including signs of active listening). The clinician talk, (7,647 turns) had 582 overlaps and 39 interruptions by patients. The main reasons for interruptions were to clarify or seek additional information. The level of experience of the clinician did not affect prevalence; however more interruptions occurred in same-gender encounters. Discussion. Communication is the most important aspect that health professionals have to master. Raising awareness of interrupting patients is important, to assist clinicians in optimising their non-specific treatment effects and enhancing patient experience. Further work is in progress to measure the impact of not listening to patients. Conclusion. Clinicians should consider their prevalence rates of interrupting patients and its impact upon care. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: Arthritis Research UK

Background. Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed. Aims. The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice. Methods. A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis. Results. Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions. Conclusion. A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice

Healthcare interventions are under increasing scrutiny regarding cost-effectiveness and outcome measures have revolutionised clinical research. To identify all available outcome questionnaires designed for lowback, lumbar spine pathologies and to perform qualitative analysis of these questionnaires for their clinimetric properties. A comprehensive e-search on PUBMED & EMBASE for all available outcome measures and published review articles for lowback and lumbar spine pathologies was undertaken over a two month period (Nov-Dec 2009). Twenty-eight questionnaires were identified in total. These outcomes questionnaires were evaluated for clinimetric properties viz:-. Validity (content, construct & criterion validity). Reliability (internal consistency & reproducibility). Responsiveness and scored on a scale of 0-6 points. Eight outcomes questionnaires had satisfied all clinimetric domains in methodological evaluation (score 6/6). Oswestry disability index (ODI). Roland-Morris disability questionnaire (RMDQ). Aberdeen lowback pain scale. Extended Aberdeen spine pain scale. Functional rating index. Core lowback pain outcome measure. Backpain functional scale. Maine-Seattle back questionnaire. Sixteen of these questionnaires scored =5 when evaluated for clinimetric domains. RMDQ had the highest number of published and validated translations followed by ODI. Criterion validity was not tested for NASS-AAOS lumbar spine questionnaire. 32%(9/28) of the outcome instruments have undergone methodological evaluation for =3 clinimetric properties. Clinicians should be cautious when choosing appropriate validated outcome measures when evaluating therapeutic/surgical intervention. We suggest use of few validated outcome measures with high clinimetric scores (=5/6) to be made mandatory when reporting clinical results

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Aims

The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life.