Background. PROMs have become an integral assessment tool of clinical effectiveness and patient satisfaction. To date, PROMs for lumbar discectomy are not an NHS requirement, although voluntary collection via the British Spine Registry is encouraged. Despite this, PROMs for day case microdiscectomy is scarcely reported. We present PROMs for day case microdiscectomy at Lancashire Teaching Hospitals. Aims. 1). To review PROMs to quantify leg pain, back pain, EQ5D and ODI scores. 2). Evaluate PROMs data collection compliance. Methods. We studied PROMs data, taken prospectively as part of routine clinical care for all patients who underwent single level day case microdiscectomy between January 2013 to December 2015. PROMs included VAS for back and leg pain, EQ5D and ODI scores. Preoperative PROMs were compared to all available postoperative PROMs at 3 months, 6 months, 12 months and 24 months. Paired student T-tests were used to compare preoperative to postoperative scores. Results. Preoperative PROMs were recorded for 132 patients. Postoperative PROMs were recorded for 48 patients at 3 months, 51 patients at 6 months, 37 patients at 12 months and 15 patients at 24 months. Significant postoperative improvements (p<0.05) were found at all time points for back pain, leg pain, EQ5D and ODI, with the exception EQ5D at 24 months (p = 0.10). Conclusion. There was significant improvement in VAS back and leg scores, as well as ODI scores over 24 months. Further work is needed to improve compliance with postoperative PROMs and to optimise the benefit of these health assessment tools. No conflicts of interest. No funding obtained

Purpose. Cognitive Muscular Therapy (CMT) is a new treatment for low back pain which integrates psychological techniques for pain management alongside training to improve postural control. Rather than focus on postural alignment or strength, CMT aims to improve the regulation of postural tone (low-level activity which supports the body against gravity). This is achieved by teaching patients an awareness of compensatory paraspinal activation, which can be triggered by overactivity of the abdominal muscles. The aim of this study was to understand whether CMT could reduce symptoms associated with low back pain and improve paraspinal muscle activation. Methods and results. Fifteen patients with chronic low back pain received seven weekly sessions of CMT from a physiotherapist. Clinical data was captured at baseline and two weeks after the intervention using the Roland-Morris questionnaire and the pain catastrophising scale. Activation of the erector spinae muscle during walking was also measured at baseline and after the final intervention session. Change data were analysed using paired t-tests. There was a 75% reduction (p<0.001) in the Roland-Morris score from a mean (SD) of 9.3(2.9) to 2.3(2.6), along with a 78% reduction in pain catastrophising (p<0.002) from 16.6(13) to 3.7(4.8). Activation of the contralateral erector spinae muscles reduced by 30% (p<0.01) during the contralateral swing phase of walking. Conclusion. In this small sample, CMT delivered large clinical improvements and reduced activation of the low back muscles during walking. Larger randomised trials are now required to confirm whether CMT could outperform existing physiotherapy treatments for chronic back pain. Conflict of interest. No conflicts of interest. Source of funding. University of Salford

Purpose of the study and background. The biopsychosocial (BPS) model is now widely implemented in clinical practice. Most research on manual therapists' attitudes regarding psychosocial (PS) factors and NSLBP is from the physiotherapy profession. There is currently no literature available to understand how osteopaths integrate those factors with patients presenting with NSLBP. The University College of Osteopathy students being the future of the profession and receiving an accredited BPS teaching warranted the need for an investigation about their attitudes towards PS factors and NSLBP. Methods and results. A qualitative research design with elements of grounded theory was used. Nine final year UCO students were recruited and interviewed at the UCO teaching centre. Data collection and analysis occurred simultaneously through the constant comparative method of analysis. Three main themes emerged from the data analysis: 1) Definition and interpretation of PS factors towards LBP; 2) Assessment and management of PS factors; 3) Competence and difficulties towards PS factors. Conclusion. The level of understanding was homogeneous amongst the participants on the understanding of PS factors and their role in a NSLBP presentation. They assessed for PS factors throughout the case history and tend to rely on their instincts. Two types of strategies towards the PS factors management were identified. However, lack of clinical experience and lack of training on the management of PS factors were identified as the main barriers encountered by students when treating patient with NSLBP. No conflict of interest. No funding

A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH. Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines. Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline. The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO

Study Aim. To design an educational resource for people with lower back pain (LBP) using creative co-production. Background. Beliefs associated with a traditional biomedical view of LBP can be a barrier to recovery. Education that reframes the problem as complex and multifactorial may help patients except and engage with more positive attitudes and behaviours. Creative co-production provides a different approach to research intervention development. It encourages a collaborative problem-solving and non-hierarchical approach to knowledge mobilisation. Method. A four-phased approach to creative co-production was used based on methods developed by the Translating Knowledge into Action (TK2A) theme of NIHR CLAHRC YH. Service users and providers were brought together in a series of workshops. Initially the lived experience of LBP was explored to generate a shared understanding of the complexities of living with and managing LBP. Then activities designed to promote divergent and convergent thinking were used for idea generation. From these ideas a series of contextually sensitive prototypes were developed and tested on a small scale. Following further iterations the final prototype, ready for implementation, was presented to all key stake holders. Results. The project produced a new interactive educational resource prototype to promote positive behaviours and attitudes for people living with LBP that can be accessed early on in the health care journey. Conclusion. The creative methods applied in this project allowed patients and staff to work together, flattening hierarchies to produce pragmatic and contextually specific outputs fit for purpose in the complex clinical environment. Project funding: Sheffield Teaching Hospitals Charitable Trust supported by National Institute for Health Research Collaborations for Leadership in Applied Research and Care Yorkshire and Humber (NIHR CLAHRC YH). No conflicts of interest

A statement of the purposes of the study and background. Lower back pain (LBP) is one of the ten leading causes of disease burden globally, producing significant detrimental effects on physical and emotional wellbeing whilst having a substantial economic burden for society. There is an inverse relationship between socio-economic status and pain prevalence. The effectiveness of a locally run ‘Back to Fitness Programme’ (6-week education and exercise programme) in the most deprived local authority area in England was evaluated. A summary of the methods used and the results. Patients at Blackpool Hospitals NHS Trust over a 6-month timeframe were included. Initial data were collected from 49 patients (mean age 53.4 years, 67% female). The amount of final data collected varied per outcome measure due to a range of factors. Participants reported the programme had helped with their understanding of pain (n=16, 100%), ability to move around and function (n=15, 94%), and level of pain (n=14, 88%). Looking at Roland Morris Disability Questionnaire scores (n=17), 88% (n=15) of patients indicated a reduction (n=12, 71%) or no change (n=3, 18%) in perceived disability. The Pain Self Efficacy Questionnaire (n=18) showed that 78% (n=14) of participants perceived an increase in their average level of confidence to move despite pain. There was an overall improvement in understanding of pain reflected by Revised Neurophysiology of Pain Questionnaire scores (n=44): 89% (n=39) improved (n=36, 82%) or did not change (n=3, 7%). Regarding lumbar flexion post-programme (n=17), 77% (n=13) of participants demonstrated an improvement (n=9, 53%) or no change (n=4, 24%). Conclusion. The majority of clinical outcomes improved following participation, predominantly in relation to understanding of pain. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by The University of Central Lancashire in partnership with The Blackpool Teaching Hospitals NHS Foundation Trust

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Introduction. The PACE trial was the first randomized controlled trial (RCT) investigating the efficacy of paracetamol in acute low back pain. Non-compliance to study medication was considered to be a limitation of this RCT. In contrast to conventional statistical methods, complier average causal effects (CACE) analysis may provide unbiased estimates of the effects for participants compliant to paracetamol. Methods. Intention to treat (ITT), as-treated, propensity weighted CACE and joint modeling CACE estimates were calculated for pain intensity, disability, global perceived effect and function at two weeks of follow up with compliance defined as an average of at least four tablets per day during the first two weeks of the trial. For pain intensity, exploratory analyses were conducted using additional time points and definitions of compliance. Results. 547 participants had been randomized to placebo and 550 to regular paracetamol; of the latter group, 72% of patients was classified as compliers. Mean differences in pain intensity between paracetamol and placebo using the main time point and definition of compliance were non-significant (ITT 0.11, p = 0.49; as-treated 0.29, p = 0.12; propensity weighed CACE −0.12, p = 0.51; joint modeling CACE 0.28, p = 0.13); similar results were obtained for disability, global perceived effect and function and for additional time points and definitions of compliance. Conclusion. In compliers, paracetamol had no significant effect on pain intensity when compared to placebo; this supports the conclusions from the original analysis. However, these calculations are based on patient-reported compliance, which may not perfectly represent actual medication consumption. Conflicts of interest: AM has received funding for a postgraduate research scholarship from GlaxoSmithKline. CM has received funding to review teaching materials prepared by GlaxoSmithKline. The other authors declare no competing interests. Sources of funding: The PACE trial was an investigator-initiated study funded by a project grant from National Health and Medical Research Council of Australia. GlaxoSmithKline Australia provided subsequent supplementary funding and the paracetamol and matched placebo. CM is supported by Australian Research Council Future Fellowships FT-100100603. CL is supported by a Career Development Fellowship from the National Health and Medical Research Council, Australia (APP1061400). This secondary analysis of the PACE data has been supported by a program grant of the Dutch Arthritis Foundation and by the Foundation “De Drie Lichten” in The Netherlands

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).

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

A statement of the purposes of the study and background. The biopsychosocial (BPS) model is recommended for managing non-specific low back pain (NSLBP) but the best method for teaching the BPS model is unclear. E-learning is a promising alternative to face-to-face methods. This study was a pilot randomised controlled trial (RCT) with embedded interview study to investigate the feasibility of conducting a main RCT and to explore the impact of an BPS for NSLBP e-learning programme on experienced practitioners' attitudes to back pain. A summary of the methods used and the results. Mixed methods evaluated the impact of an evidence-based e-learning programme on participants' attitudes to back pain. A pilot RCT assessed 45 experienced osteopaths' attitudes before and after the intervention, using the Pain Attitudes and Beliefs Scale (PABS) and the Attitudes to Back Pain Scale (ABS). The qualitative study explored 9 participants' views on the e-learning programme and possible impact on their clinical practice. 91% of participants completed the course and the overall satisfaction was very high. Participants' views on the BPS model ranged between not being structural enough, already done and transformative. The e-learning programme was well accepted. It would be feasible to run a main study using the same recruitment procedures, eligibility criteria, randomisation procedure, consent process, data collection and outcome measures. Conclusion. E-learning is an appropriate tool to deliver CPD to experienced manual therapists. Although a pilot study, the results suggest a shift in practitioners' attitudes towards a more BPS view of back pain. A main trial should be undertaken to test the effectiveness of the intervention. No conflicts of interest. Funding acknowledgements: This research is part of Jerry Draper-Rodi's Professional Doctorate in Osteopathy, partly funded by the British School of Osteopathy

Purpose:. To produce objective evidence that lifting is more comfortable in lumbar flexion than lumbar extension. Traditionally, lifting is taught in lumbar extension (“straight back”) but in our experience is more comfortable and stronger in flexion with backward lumbar tilt. Method and results:. 58 subjects performed maximal comfortable static lifts:. 1. ‘Natural’ lifting position - hip flexion, knee extension, lumbar extension. 2. Traditionally taught position - hip flexion, knee flexion, lumbar extension. 3. Backward pelvic tilt - hip flexion, knee flexion, lumbar flexion. The order of these lifting methods varied to allow for variation due to fatigue/recruitment. All lifts were measured with a computerised dynamometer. The mean force for natural lifting was 13.4 kgs, for traditionally taught lifting 15.1 kgs and for backward pelvic tilt lifting 22.2 kgs. This represented a 13% greater load for traditionally taught lift compared with natural lift, 66% greater for backward pelvic tilt compared with natural lift and 48% greater for backward pelvic tilt compared with traditionally taught lift. Conclusion:. Contrary to accepted teaching and intra-discal pressure studies, this study confirms the observation that lifting strength is greater when the lumbar spine is in flexion. Thus, patients can avoid provoking their back pain when lifting by flexing the lumbar spine. A possible explanation is reduced facet joint compression in lumbar flexion and load sharing with the lumbar fascia and ligaments

Aims

The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood.

Purpose and Background. Leg length discrepancy (LLD) occurs commonly and has been associated with osteoarthritis of the knee and the hip joints. However, the possible association between LLD and degenerative changes in the lumbar spine has not been investigated. Here we correlate the degree of LLD with degenerative changes in the hip joints and the lumbar spine. Methods and Results. A modification of Friberg's method was used to measure LLD and a novel method was devised to exclude magnification errors in standing radiographs of the lumbopelvic region. 5mm of LLD was considered significant. 75 sets (36 female and 39 male) of radiographs from adult patients presenting to chiropractic teaching clinics were used. Degenerative changes at hip and L4/5 and L5/S1 disc spaces were graded on a 4-point scale. Hip degeneration in men with significant LLD was [mean, 95% confidence interval] [1.35, 1.05–1.66], as opposed to men with no significant LLD [0.31, 0.1–0.53]. Degenerative changes at the L5/S1 spinal level in the group with significant LLD demonstrated values of [1.04, 0.75–1.33], compared to the group without significant LLD with values of [0.41, 0.22–0.61]. The association between LLD and lumbar degeneration was particularly strong in men and also in women at or above the age of 25. Conclusion. Here we demonstrate that LLD of 5mm or above, as measured by our method, is associated with significant degenerative changes in the hip joint in men and the L5/S1 motion segment in both men and women, but may be more significant in older women. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Surgery for spinal deformity was previously carried out only in teaching hospitals in the United Kingdom. With increasing numbers of patients especially adults, seeking treatment for spinal deformity, the number of centres offering treatment for spinal deformity is going to have to increase. The deformity part of the Spinal Surgical Service in the District General Hospital in Taunton started in 2005. This paper is an audit of this deformity service. It looks at two key areas – that of patient satisfaction and patient reported outcomes of surgery. Patient satisfaction was assessed by a validated questionnaire that evaluated a patient's perception of consultations, consent, preoperative assessment, operative and post operative experience and follows up visits. Patient reported outcomes were evaluated using the SRS 30 questionnaire. 104 patients were contacted and 95 patients (91%) responded. The overall patient satisfaction rate was 96%, with 87% very pleased with the result of surgery, 80% felt that their body shape had improved considerably, 62% had an increased ability to carry out day to day activities to a much higher level and 78% had significantly decreased pain after surgery. The results of the different domains of the SRS questionnaire also supported this. The authors believe that this audit proves that it is possible to provide a spinal deformity service in a District General Hospital in the United Kingdom safely and effectively with a high degree of patient satisfaction. Audits of this kind are required to compare results of treatment between different centres and establish standards

Aims

HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients’ CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them.

Aims

The purpose of this study was to investigate the prevalence of sarcopenia and to examine its impact on patients with degenerative lumbar spinal stenosis (DLSS).

Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84 655 patients undergoing posterior lumbar fusion were identified and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood product transfusion and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation.

In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18).

Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians.

Cite this article: Bone Joint J 2014;96-B:242–8.