Aims. Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS. Methods. POSE was offered to 150 prospective patients over ten months (December 2018 to November 2019) Some chose to attend (Attend-POSE) and some did not attend (DNA-POSE). A third independent retrospective group of 150 patients (mean age 57.9 years (SD 14.8), 50.6% female) received surgery prior to POSE (pre-POSE). POSE consisted of an in-person 60-minute education with accompanying literature, specified using the RTSS as psychoeducative treatment components designed to optimize cognitive/affective representations of thoughts/feelings, and normalize anxieties about surgery and its aftermath. Across-group age, sex, median LOS, perioperative complications, and readmission rates were assessed using appropriate statistical tests. Results. In all, 65 (43%) patients (mean age 57.4 years (SD 18.2), 58.8% female) comprised the Attend-POSE, and 85 (57%) DNA-POSE (mean age 54.9 years (SD 15.8), 65.8% female). There were no significant between-group differences in age, sex, surgery type, complications, or readmission rates. Median LOS was statistically different across Pre-POSE (5 days ((interquartile range (IQR) 3 to 7)), Attend-POSE (3 (2 to 5)), and DNA-POSE (4 (3 to 7)), (p = 0.014). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (p = 0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparation, procedural familiarity, and less anxiety. Conclusion. POSE was associated with a significant reduction in LOS for patients undergoing spinal fusion surgery. Patients reported being better prepared for, more familiar, and less anxious about their surgery. POSE did not affect complication or readmission rates, meaning its inclusion was safe. However, uptake (43%) was disappointing and future work should explore potential barriers and challenges to attending POSE. Cite this article: Bone Jt Open 2022;3(2):135–144

Background. Immersive virtual reality (VR) demonstrates potential benefits in patients with chronic low back pain (CLBP). However, few studies have investigated the feasibility and the acceptability of introducing immersive VR for use with patients with CLBP and in the Kingdom of Saudi Arabia (KSA). Aim. To investigate immersive VR's feasibility, tolerability, and acceptability as a rehabilitation intervention for adult patients with CLBP and explore the views of relevant Health Care Practitioners (HCPs) in the KSA. Methodology and Methods. A multi-centre, mixed-methods, explanatory sequential design was adopted to test immersive VR's feasibility, tolerability, and acceptability. An uncontrolled feasibility trial was conducted. The immersive VR intervention involved a training session followed by three sessions over one week using commercially available hardware and software. Feasibility outcomes were collected from patients immediately post-intervention. Patients and HCPs were recruited for semi-structured interviews. Results. Thirty-three patients and three HCPs were recruited. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, treatment compliance and fidelity. Adverse events included one who reported aggravation of tinnitus, whereas two experienced dizziness. Qualitative data suggested that entertainment and motivation were key enablers. Barriers included technological capability and HCPs’ perceptions that immersive VR was time-consuming. Conclusion. The results suggested that immersive VR was feasible, acceptable, and tolerable among patients with CLBP and HCPs in clinical settings in the KSA. Further research focusing on the effectiveness is warranted in this field. Conflicts of Interest. None. Sources of Funding. None. Trial registration number. ISRCTN14434517

Purpose and Background. Work-related musculoskeletal disorders (WRMSD) can affect 56–80% of physiotherapists. Patient handling is reported as a significant risk factor for developing WRMSD with the back most frequently injured. Physiotherapists perform therapeutic handling to manually assist and facilitate patients’ movement to aid rehabilitation, which can increase physiotherapists risk of experiencing high forces during patient handling. Methods and Results. A descriptive cross-sectional study was completed to explore and quantitatively measure the movement of ten physiotherapists during patient handling, over one working day, in a neurological setting. A wearable 3-dimensional motion analysis system, Xsens (Movella, Henderson, NV), was used to measure physiotherapist movement and postures in the ward setting during patient treatment sessions. The resulting joint angles were reported descriptively and compared against a frequently used ergonomic assessment tool, the Rapid Upper Limb Assessment (RULA). Physiotherapists adopted four main positions during patient handling tasks: 1) kneeling; 2) half-kneeling; 3) standing; and 4) sitting. Eight patient handling tasks were identified and described: 1) Lie-to-sit; 2) sit-to-lie; 3) sit-to-stand; facilitation of 4) upper limb; 5) lower limb; 6) trunk; and 7) standing treatments; and 8) walking facilitation. Kneeling and sitting positions demonstrated greater neck extension and greater lumbosacral flexion during treatments which scores highly with the RULA. Conclusion. This research identified that patient treatment tasks were more often performed in kneeling or sitting positions than standing. Current moving and handling guidance teaches moving and handling in a standing position; loading and stresses experienced by the physiotherapists may differ in sitting or kneeling positions. Conflicts of interest. None. Sources of funding. None. This work has been presented as a poster at the CSP conference Glasgow 2023

Background. Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques. Methods. PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios. Results. Differences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented. Conclusion. The study is due to open in May 2024 and complete in 2026. Conflicts of Interest. No conflicts of interest declared. Sources of Funding. NIHR Health Technology Award – grant number NIHR153170. Trial presentations so far. APOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024

Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Purpose of the study and background. An integrated rehabilitation programme was developed and found feasible taking into account the existing evidence base, appropriate theories, and patient and public involvement. The integrated programme encompasses inpatient activities supported by a multidisciplinary team, and integration of knowledge, skills and behaviours in the patient's everyday life. The aim of this trial was to compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain (CLBP). Methods and Results. Comparison of two parallel rehabilitation programmes in a randomised controlled trial including 165 patients with CLBP. The integrated rehabilitation programme comprised an alternation of in total three weeks of inpatient stay and in total 11 weeks of home-based activities. The existing rehabilitation programme comprised a four-week inpatient stay. Primary outcome was changes in disability (Oswestry Disability Index). Secondary outcomes were changes in pain, pain self-efficacy, health related quality of life and depression. Outcomes were collected at baseline and 26-week follow-up. Disability decreased −5.76 (95%CI; −8.31, −3.20) for the integrated programme and −5.64 (95%CI; −8.45, −2.83) for the existing programme. The adjusted difference between the two programmes was −0.28 (95%CI; −4.02, 3.45). No statistically significant difference was found in any of the secondary outcomes. Conclusion. The results of the trial were consistent, showing no significant differences in patients' outcomes when comparing an integrated rehabilitation programme with an existing programme. Conflicts of interest: None. Sources of funding: Aarhus University, The Danish Rheumatism Association and Familien Hede Nielsens Fond

Background. Free From Pain (aka Fear Reduction, Exercise Early with Food from plants, Rest and relaxation, Organisation and Motivation to decrease Pain from Arthritis and Increase Natural Strength) is a functional rehabilitation programme to combat sarcopenia and musculoskeletal pain in seniors. It is also published as a book (ISBN-0995676941). The aim of this audit was to evaluate the safety and suitability of the exercises and the usefulness of the exercise book. Methods and Results. Participants were volunteers who paid to attend the Free From Pain Exercise programme. Participants evaluated the exercises using a 5-point Likert scale and the Exercise Book using the Usefulness Scale for Patient Information Material (USE). 30 participants attended the Free From Pain programme. 26 participants completed the questionnaire. This included 20 females and 6 males, with a mean age of 76 years. The mean scores on the 0 to 5 Likert scales were A) Exercises were suitable? 4.69; B) Exercises were safe? 4.58; C) Absence of any injury or medical event whilst exercising? 4.58; D) Covered all body parts? 4.38; E) Easy to do at home? 4.42; F) Encouraged to do more exercise? 4.42; G) Recommend to family and friends? 4.50. The mean scores of the cognitive, emotional, and behavioural sub domains of the USE scale, scored 0 to 30, were 25.23, 23.73 and 23.69, respectively. Conclusion. The pre-pilot study suggests that the suggested exercises are safe and suitable for seniors, and that the exercise book is holistically useful. Conflict of Interest: G Ampat sells the Free From Pain Exercise book online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Free From Pain is a trading name. Jacqueline Howard is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

Purposes and Background. Musculoskeletal disorders including as back and neck pain are leading causes of work disability. Effective interventions exist (i.e. functional restoration, multidisciplinary biopsychosocial rehabilitation, workplace-based interventions, etc.), but it is difficult to select the optimal intervention for specific patients. The Work Assessment Triage Tool (WATT) is a clinical decision support tool developed using machine learning to help select interventions. The WATT algorithm categorizes patients based on individual, occupational, and clinical characteristics according to likelihood of successful return-to-work following rehabilitation. Internal validation showed acceptable classification accuracy, but WATT has not been tested beyond the original development sample. Our purpose was to externally validate the WATT. Methods and Results. A population-based cohort design was used, with administrative and clinical data extracted from a Canadian provincial compensation database. Data were available on workers being considered for rehabilitation between January 2013 and December 2016. Data was obtained on patient characteristics (ie. age, sex, education level), clinical factors (ie. diagnosis, part of body affected, pain and disability ratings), occupational factors (ie. occupation, employment status, modified work availability), type of rehabilitation program undertaken, and return-to-work outcomes (receipt of wage replacement benefits 30 days after assessment). Analysis included classification accuracy statistics of WATT recommendations for selecting interventions that lead to successful RTW outcomes. The sample included 5296 workers of which 33% had spinal conditions. Sensitivity of the WATT was 0.35 while specificity was 0.83. Overall accuracy was 73%. Conclusion. Accuracy of the WATT for selecting successful rehabilitation programs was modest. Algorithm revision and further validation is needed. No conflicts of interest. Sources of funding: Funding was provided by the Workers' Compensation Board of Alberta

Purpose. The behavioural change wheel methodology and social cognitive theory were combined to inform and develop a rehabilitation programme following lumbar fusion surgery (REFS). This qualitative study evaluated participant's experiences of lumbar fusion surgery, including REFS, to identify valued programme content (‘active ingredients’). Background. A feasibility-RCT suggested REFS achieved a meaningful impact in disability and pain self-efficacy compared to ‘usual care’ (p=0.014, p=0.007). In keeping with MRC guidance a qualitative evaluation was undertaken to understand possible mechanisms of action. Methods. Thematic analysis was utilised on data from semi-structured, face-to-face interviews, in a purposive sample (REFS n=10, ‘usual care’ n=10). Results. Three themes (8 sub-themes) were identified, which illuminated the experiences of 1) the impact of living with a chronic lumbar disorder 2) reflections on recovery, and 3) the experience of rehabilitation with(out) REFS. REFS participants identified valued programme content including the opportunity for vicarious learning, the shared rehabilitation experience, and expert physiotherapy. They were unable to identify pre-eminent programme content, in keeping with inter-dependent ‘active ingredients’. Abstraction with the overarching theme of ‘loss of self’ was evident for analysis across all themes. Conclusion. In conclusion the findings were theoretically congruous with other published works e.g. recent mega-ethnographic review of patients experience of chronic non-malignant pain. Two emergent areas were identified to inform future REFS iterations and better understand potential mechanisms of action. 1-Participants fear of harm appears directly attributable to the instillation of metalware, this association is mediated by inadequate advice. 2-Lumbar fusion surgery is not perceived as elective. No conflicts of interest. Funding; NIHR (Doctoral fellowship, awarded to J Greenwood)

Introduction. Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone. Planning Methodology. First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies. Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken. Results. Patient rehabilitated well and was discharged after 42 days. Patient underwent SABR two months post-operatively. Despite left foot drop, she was walking independently 9 months post-operatively. Conclusion. These challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR for maximum local control

Background and Purpose. Non-specific chronic low back pain (NSCLBP) poses a significant disability and economic burden worldwide. Fear avoidance is suggested to contribute to its chronicity and reduced treatment effect. National guidelines recommend exercise as a component of multidisciplinary rehabilitation but its interaction with fear avoidance is ambiguous. This systematic review examined the effect of exercise-based interventions (EBIs) on fear avoidance NSCLBP. Methods and Results. RCTs comparing EBIs to usual care in adults with NSCLBP were included. A systematic search of CINAHL, Medline, EMBASE, Web of Science, Scopus and Cochrane Library (up to January 2019) revealed 10 eligible trials. Following risk of bias assessment, 6 studies were included for data extraction and narrative synthesis. EBIs were not found superior to usual care in reducing fear avoidance at any follow-up. There was evidence that reducing fear avoidance is probably not the mechanism through which EBIs affect pain and disability. In adherent patients, EBIs did not result in greater clinically relevant improvements in pain or disability than usual care, in the short- or intermediate-term. Conclusion. Addition of EBIs as part of multidisciplinary rehabilitation is not more beneficial than that of usual care in reducing fear avoidance in NSCLBP patients. However, the findings of this review are based on heterogenous studies presenting with methodological limitations. Further high-quality research is required to examine the review's findings and investigate current physiotherapy management of fear avoidance in NSCLBP. No conflicts of interest. No funding obtained

Purpose. The aim of this study was to explore the usefulness and feasibility of comprehensive vocational rehabilitation (C-VR) and less comprehensive vocational rehabilitation (LC-VR) for workers on sick leave due to CMP, from the perspective of patients, professionals, and managers. Methods. Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, interviewees were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using thematic analysis. Results. Thirteen patients (n=6 C-VR, n=7 LC-VR), eight professionals, and nine managers were interviewed. Three themes emerged for usefulness (‘patient factors’, ‘content’, ‘dosage’) and six themes emerged for feasibility (‘satisfaction’, ‘intention to continue use’, ‘perceived appropriateness’, ‘positive/negative effects on target participants’, ‘factors affecting implementation ease or difficulty’, ‘adaptations’). Patients rated both programs as positive. According to adaptations, the professionals reported that they desired more flexibility in content, dosage and choice of program. Conclusions. The patients reported that both programs were feasible and generally useful. The professionals preferred working with the C-VR, although they disliked the fixed and uniform character of the program. They also mentioned that this program is too extensive for some patients, and that the latter would probably benefit from the LC-VR program. Despite their positive intentions, the managers stated that due to the Dutch healthcare system, implementation of the LC-VR program would be financially unfeasible. No conflicts of interest. No funding obtained

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

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

Aims

Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aims

Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes