Introduction. Low back pain is the leading cause of musculoskeletal disease and the biggest cause of morbidity worldwide. Approximately 40% of these are cases are caused by disease of the intervertebral discs (IVDs): the shock absorbing, flexible material located between the bones (vertebrae) along the length of the spine. In severe cases, the spine becomes unstable and it becomes necessary to immobilise or fix the joint in position using a lumbar cage spacer between in the IVD and metal pins with supporting plates in the vertebrae. This is a complex, expensive, major surgery and it is associated with complications, such as spinal fusion failure and inappropriate implant position. These complications have a dramatic impact on the quality of life of the affected patients and the burden to society and the healthcare system is exacerbated. Methods and Results. We present an in vitro study looking at the effect of our Bgel hydrogel on mesenchymal stem cells (MSCs) and their bone forming capacity within lumbar cages: devices used to space the bones apart in the fusion operation, as a mechanism to improve fixation and intra cage bone formation. MSCs were isolated from human hip joint, expanded, seeded within Bgel, cast into well inserts or lumbar cages and cultured for 4 weeks. Using 3D X-ray imaging micro computed tomography (μCT) scans we show that the MSC in the presence Bgel begin to mineralise within the lumbar cages. Histology is currently ongoing and will be presented at the meeting. Conclusion. This study shows the potential to improve current spinal fusion practices with the potential to reduce complications. Conflicts of interest: CS and CLM are named inventors on the patent for NPgel/BGel. Funded by the Medical Research Council and Versus Arthritis UK: SNiPER

Purpose & Background. Back and lower limb injuries are prevalent in athletes who perform novel weight-lifting techniques with inappropriate kinematics. Visual-auditory instructions and knowledge of performance (KP) verbal instructions are utilised to help novices execute novel skills. Effectiveness of these methods on executing appropriate front-squat lifting kinematics is limited. Aim: to investigate the effects of visual-auditory instructions compared to KP verbal instructions on front-squat kinematics at sticking point in novice lifters, with improvement determined by proximity to the kinematics of an expert lifter at sticking point when performing optimal front-squat lift. Methods. Twenty-four novices were randomised into two groups and performed front-squat lift. The novices in visual-auditory group (n = 12, age = 24.33 ± 2.93 years) received videoaudio instructions, verbal group (n = 12, Age= 22.66 ± 2.34 years) received KP verbal instructions. MATLAB software measured kinematic lumbar angles, Kinovea software measured hip, knee, ankle angles at sticking point of front-squat. Data were collected from video recordings of novices and an expert pre-and post-instructions in one session and expert data were used as reference values of proximity for both groups. Results. No significant differences were found between groups in lumbar, hip, knee, and ankle angles at sticking point of front-squat lift, where improvement was determined by proximity to expert lifter's angles. There was significant improvement with in lumbar angle of both groups and hip angle (verbal group). Conclusion. Visual-auditory instructions and verbal instructions have similar effects on the front-squat kinematics (lumbar spine, hip knee and ankle) of novice lifters. No Conflict of Interests. No funding was obtained

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. Methods. Qualitative, semi-structured interviews were conducted with general practitioners, spinal specialist physiotherapists and spinal surgeons (n=20 in total). Interviews were fully transcribed, and data were analysed using the constant comparison method. Results. Across all groups, clinicians identified potential added value in ‘fast-tracking’ some sciatica patients in terms of patient reassurance based on MRI scan findings. Whilst spinal physiotherapists felt that most ‘fast track’ patients were appropriate, some spinal physiotherapists and GPs had concerns that patients with symptom durations of less than 6 weeks might be inappropriately fast-tracked since their symptoms may still resolve without the need for invasive treatments. Spinal surgeons felt it was acceptable for patients with short symptom durations to be ‘fast-tracked’, but to provide early reassurance rather than direct treatment. Conclusion. Whilst clinicians saw added value in a group of sciatica patients being ‘fast-tracked’ to specialist opinion, there was some reservation about moving away from the usual stepped care, ‘wait and see’ approach for patients with short symptom duration. Conflicts of interest statement. No conflicts of interest. Sources of funding. This study is funded by the National Institute for Health Research Health Technology Assessment Programme (NIHR HTA project number 12/201/09) and will be published in full in Health Technology Assessment. Funding support is also received from an NIHR Research Professorship for Nadine Foster (NIHR-RP-011-015), who is an NIHR Senior Investigator, and a HEFCE Senior Clinical Lecturer award for Kika Konstantinou. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health and Social Care. The study was approved by the NRES Committee West Midlands – Solihull, 17/03/2015, ref: 15/WM/0078. Trial registration: ISRCTN75449581

We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques

Summary. Each patient received Cognitive Reassurance appropriate for and proportionate to his/her capacity through evidence informed explanation/education to enhance effective self-care and realistic self-management. Background and pathway. Changes to back and neck pain commissioning by our CCG required GPs not to refer to manual therapy until six weeks and upgrade GP care beyond that previous. 100 consecutive patients requesting GP appointment reporting back/neck pain were directed to a pragmatic service provided by an experienced manual therapy practitioner. Cognitive Reassurance reflecting evidenced informed biopsychosocial and salutogenic thinking was given at initial consultation/assessment. Patients were contacted at 10 and 20 days to ascertain their status. One sub-group suggested an opportunity for long-term follow-up. Pilot Objectives. Providing Cognitive Reassurance for achieving greater levels of patient engagement with self-management. Demonstrate full clinical triage by primary care providers is effective/practical. Demonstrate a need for appropriate contracting models. ————————–. Outcomes 100 patients. Wait time. 2d. Inappropriate self-referral directed to GPs. 25%. DNAs. 7%. Referral for medication –. 28%. Prescribed AQP manual therapy. 35%. Outcomes 36 patients decided at 20 days no further treatment needed . Treatments averaged. 1.8/pt (Range 0–4). Patients deciding no treatment needed beyond initial consultation. 4%. Patients requesting further consultation during the 12 months following:. 4%. Conclusion. Patient experience measured by an external moderator showed 94% highly satisfied or satisfied. Clinical triage was acceptable to patients and GPs. Adapting to the needs of each patient requires a more pragmatic model of contracting to be created. The opportunity for a further pilot are considered

Purpose. To compare the incidence and nature of ‘neurophysiological events’ identified, post hoc, by a consultant neurophysiologist with those identified intra-operatively by clinical physiologists, before and after intervention(s). Methods. The IOM wave-recordings, event-logs and reports of all spinal deformity cases conducted by a team of clinical physiologists from April to June 2009 (Group 1) were reviewed retrospectively by the same, experienced clinical neurophysiologist, (MG). Interventions were then agreed. The first was to alter the IOM report document to drop down menus. The second was to arrange a series of teaching sessions for the clinical physiologists on a variety of aspects of IOM. Finally during these teaching sessions recent cases were brought to review in an informal setting to discuss. Following implementation of the interventions a further review from April to June 2010 (Group 2) was carried out in the same manner. The clinical physiologists did not know the time periods over which the review would be taking place. Results. From April to June 2009 (Group 1) thirty two patients were studied and from April to June 2010 (Group 2) thirty four patients were studies. Group 1. Twenty seven of these had been monitored using ‘multimodal’ IOM consisting of cortical (CSEP) and spinal (SSEP) somatosensory evoked potentials and motor (MEP/CMAP) evoked potentials. Two patients were inappropriate for MEP recording and two were monitored using epidural SSEP recording. During 10 operations (31%) the surgeons were notified of an ‘intra-operative neurological event’ judged by the clinical neurophysiologist as potentially requiring a surgical response. When the results were audited, only 2 (6%) of these ‘events’ were considered by the consultant clinical neurophysiologist to represent ‘true positive’ intra-operative neurophysiological findings. Group 2. Twenty six of these had been monitored using ‘multimodal’ IOM consisting of cortical (CSEP) and spinal (SSEP) somatosensory evoked potentials and motor (MEP/CMAP) evoked potentials. Four patients were inappropriate for MEP recording and had a combination of SSEP and CSEP. The remainder had IOM with unimodal. No epidural IOM was used during this period. During 4 operations (12%) the surgeons were notified of an ‘intra-operative neurological event’ judged by the clinical neurophysiologist as potentially requiring a surgical response. Post-operative examination of all the patients in both groups revealed that no ‘false negative’ conclusions had been reached. Conclusion. In this series clinical physiologists were found to alert the surgeons 5 times more frequently than was likely to have been the case with an experienced consultant clinical neurophysiologist (31% and 6% respectively). However the increased reporting of intra-operative events did not result in any alteration of the ultimate surgical strategy in any operation although tactical changes were sometimes necessary during the operation in order to test the reversibility of the flagged event. The implementation of two simple interventions resulted in the clinical physiologists alerting the surgeons only 1/3 of that previously (12%) of cases. The log indicated that on all occasions appropriate surgical action had been taken with no residual neurological deficit. This study, owing to its size, cannot answer the key question of safety. Further work to estimate the statistical power required of such a study is being sought. In the interim proving a track record of successful cases provides evidence of efficacy. Ethics Approval: None. Interest Statement: None

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

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We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

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The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

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The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

Background. Current policy and practice aimed at tackling work disability due to low back pain is largely aligned with the Psychosocial Flags Framework, which focuses on addressing individual beliefs and behaviours (yellow and blue flags). However, our understanding of the systemic and contextual factors (black flags) that are also proposed to act as obstacles within this Framework is under-represented, resulting in a disproportionate evidence base and suboptimal interventions. Methods. A ‘best-evidence’ synthesis was conducted to collate the evidence on those ‘black flags’ proposed to be the most important: compensatory systems (worker's compensation and disability benefits), healthcare provider systems and ‘significant others’ (spouse/partner/close family members). A systematic search of scientific and grey literature databases was performed, and the validity and merit of the available evidence was assessed using a system adapted from previous large-scale policy reviews conducted in this field. Results. Following a systematic exclusion process, 65 articles were selected from 1,762 records. Robust, credible and meaningful evidence was found to show that inflexible compensatory systems, a lack of ‘work-focused’ healthcare and communication amongst return-to-work stakeholders, along with inappropriate support from ‘significant others’ are obstacles to work participation for those with low back pain. Conclusions. This is the first attempt at synthesising the evidence on the ‘social’ factors proposed to be important influences on work disability due to low back pain within the Psychosocial Flags Framework. Results have relevance to researchers, policy makers, clinicians and employers, with wider implications for the revision of current psychosocial policy and practice. No conflicts of interest; no funding obtained

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

MRI scanning of spinal patients at the Primary Care Triage stage is pivotal in reducing inappropriate referrals into Secondary Care. A retrospective study was undertaken. Details of patients from spinal triage clinics referred for MRI scan were collated together with a provisional diagnosis. Following imaging the results and management plan were documented. 2191 Patients referred via GP's to Physiotherapy Specialist- lead spinal triage clinics from April to September 2009 inclusive. Referred to a spinal consultant routine/urgent, Managed conservatively, Failed to attend for MRI scanning or MRI cancelled, Sent for scanning for reassurance and discharged. Of 2191 patients seen in a 6-month period 194 (9%) were referred for MRI of which 81 (41%) were referred on to spinal consultant. This equates to 3.7% of the total number of patients triaged. Specialist physiotherapy diagnosticians with access to MRI scanning, allows simultaneous treatment and seamless transfer to spinal consultants for surgical intervention if appropriate. 1. This process is used effectively to manage large numbers of spinal referrals and minimises the number of patients seen unnecessarily in secondary care. 1. This is only possible with close multidisciplinary team working. 2.

Purpose of the study. To compare safety and efficacy of cervical disc replacement (CRD) in single and multilevel DDD. Patients were followed up at 1, 3, 6, 12 and 24 months. Methods. 249 patients were enrolled. 171 patients were treated at 1-level, 41 treated at 2 levels and 2 patients were treated at 3 levels. Implant was also used adjacent to a fusion with a cage in 35 patients. The diagnosis was cervical degenerative disc disease between C3 and C7 with symptomatic DH. Population was 106 male 143 female, average age 46 (25-71). Clinical assessment included VAS scores for arm and neck pain and Neck Disability Index (NDI). Range of motion (ROM) from flexion/extension lateral view were measured. Results. Of all NDI scores recorded, 86,50 % demonstrated at least 15 points improvement at two years follow up from pre-op scores. 85,1% of VAS arm Pain scores demonstrated an improvement by = 2 points from pre-op scores and 50,8% for VAS neck Pain scores. The breakdown by levels and adjacent to an interbody cage shown that 80% of reported NDI scores demonstrated at least a 15 point improvement post operatively for two level disc replacement. 82,4% demonstrated a greater than 2 points improvement in VAS arm pain and 53,3% for VAS neck pain. For patients that received both implant and an interbody cage, 72,7% demonstrated a greater than 2 point improvement in VAS arm pain and 41,7% for VAS neck pain. Three (1,8%) cases of subsidence and 4 cases of implant loosening/displacement due to inappropriate sizing were reported. Available radiographic findings show on average a ROM of 8,2 ° at 2 years and an overall change in cervical lordosis of 5° from pre-op. Conclusion. Clinical outcomes demonstrated a significant improvement for both the total population (n=249) and for the single level total disc replacement population (n=171). Given these outstanding results single and multilevel TDR with this implant can be considered to be safe. No significant difference was observed between single and multilevel TDR groups regarding clinical, functional and radiological results. Follow up for this series need however to be extended for up to 5 years at least. The role of this implant in multilevel cases as well as in cases to a fused level still need further evaluation although these preliminary results are encouraging

Aims

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

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The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease.

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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.

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Aims

A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed.

Minimal clinically important differences (MCID) in the scores of patient-reported outcome measures allow clinicians to assess the outcome of intervention from the perspective of the patient. There has been significant variation in their absolute values in previous publications and a lack of consistency in their calculation.

The purpose of this study was first, to establish whether these values, following spinal surgery, vary depending on the surgical intervention and their method of calculation and secondly, to assess whether there is any correlation between the two external anchors most frequently used to calculate the MCID.

We carried out a retrospective analysis of prospectively gathered data of adult patients who underwent elective spinal surgery between 1994 and 2009. A total of 244 patients were included. There were 125 men and 119 women with a mean age of 54 years (16 to 84); the mean follow-up was 62 months (6 to 199) The MCID was calculated using three previously published methods.

Our results show that the value of the MCID varies considerably with the operation and its method of calculation. There was good correlation between the two external anchors. The global outcome tool correlated significantly better.

We conclude that consensus needs to be reached on the best method of calculating the MCID. This then needs to be defined for each spinal procedure. Using a blanket value for the MCID for all spinal procedures should be avoided.

Cite this article: Bone Joint J 2015;97-B:366–71.