Introduction: Following surgical discectomy for pro-lapsed lumbar intervertebral disc, a proportion of patients develop leg symptoms on the side contra-lateral to the original surgery. Among other causes, subsequent disc space narrowing together with on-going degenerative changes may cause root entrapment in the lateral recess or in the intervertebral canal at the level of the previous disc prolapse.

It has been previously reported that the results of discectomy are less successful in patients with pre-existing spinal stenosis. It may be argued that patients with a narrow spinal canal would be more prone to the development of contra-lateral symptoms. The aim of this study was to determine whether any measurement on the pre-operative CT scan could predict the development of contra-lateral symptoms, or provide an indication for prophylactic decompression of the contra-lateral side at the time of the original surgery.

Materials & Methods: In a retrospective cohort of 43 patients following lumbar discectomy, eight subsequently developed symptoms on the contra-lateral side of whom three required subsequent contra-lateral surgery. A relationship was demonstrated between a measurement taken on the pre-operative CT scan (the oblique sub-facet distance) and the occurrence of contra-lateral symptoms following discectomy.

Conclusion: An oblique sub-facet distance of 8mm or less predicted the development of contra-lateral symptoms with a sensitivity of 75 % and a specificity of 74%.

Aims: We aim to investigate how often we needed extensive investigations to reach a speciþc diagnosis and whether we could identify symptoms and signs predictive of such diagnosis. Methods: We analysed the records of 60 children referred to our specialist clinics complaining of back pain. We statistically analysed the speciþcity of 9 parameters from history and clinical examination to predict the þnal diagnosis and checked the correlation between initial clinical diagnosis and þnal diagnosis following extensive investigations such as bone scan, CT and MRI scan. Results: The mean age of our group of patients was 12.3 years (range=3–18 years). We failed to reach a speciþc initial diagnosis after history taking, clinical examination and simple X-rays of the spine in 33 patients (55%). By the completion of investigations a speciþc diagnosis was not reached in only 18 (35%), and the difference was signiþcant compared to the other 65% (chi square(1)=4.41, p< 0.05). In 15 children specialist investigations clariþed a diagnosis of spondylolysis, Scheuermannñs disease and tumour. A hypothesised set of 9 clinical symptoms and signs was not predictive of speciþcity of initial clinical diagnosis (RL 2=0.12, chi square (9)=10.07, p> 0.05), but was predictive of þnal diagnosis (RL 2=0.35, chi square(9)=22.88, p< 0.01). A speciþc diagnosis was less likely in the presence of activity related pain or intermittent pain. There was a high degree of correlation between initial clinical diagnosis and þnal diagnosis. (phi=0.70, chi square(1)=25.07, p< 0.001). Conclusions: For about half our group of children, back pain was not a speciþc symptom. A set of common set of clinical symptoms and signs did not initially predict speciþcity. Based on these initial þndings we should continue to investigate in depth any referred child with back pain.

Introduction : The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patient. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients.

Objective: To quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score in patient’s treated conservatively for Mechanical Low Back Pain.

Design & Subject: Postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Outcome measures: Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusions: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Introduction: The ultimate aim of any treatment for low back ache is to improve the quality of life as perceived by the patients. Changes in the condition specific disability measures like the Low Back Outcome Score are used as a measure for this purpose and the results interpreted in terms of statistical significance. It is not known, however, if these changes are considered to be clinically significant by the patients. This study quantifies the Minimum Clinically Important Difference (MCID) of Low Back Outcome Score from the patient’s perspective that were treated conservatively for Mechanical Low Back Pain.

Method: In August and September 1999, a postal questionnaire was sent to a randomly selected cohort of 300 individuals who were treated in the Spinal Assessment Clinic (SAC) for low back pain.

Patient’s perception of the outcome of the rehabilitation programme was compared with the changes in LBOS from the time of initial presentation to the postal questionnaire.

Results: 186 forms (62 % response rate) were returned. Data from 170 forms were analysed, as 16 forms were incomplete. An average improvement of 17.96(p=0.001) in 75-point LBOS was noticed in those (n = 61) who reported complete recovery. Those who reported Good but incomplete recovery ( n =61) improved their LBOS by 12.37 points( p=0.001). LBOS improvement of 7.52 points ( p = 0.002) was noticed in patients reporting a minimal improvement( n= 38). Ten patients had no change in their clinical condition ( LBOS change 2.8, p =0.485).Age and gender distribution of four groups remained same ( chi square = 1.39, df = 3,p > 0.5).

Conclusion: The Minimum Clinically Important Difference for patients with Low Back Pain is a 7.5 (10%) change in the 75 point LBOS. An average change of 12 (16%) and 18(24%) can be considered to be Good and Excellent responses respectively to the treatment as perceived by the patients. This data will help to determine whether a statistically significant result is clinically meaningful.

Introduction: After a year in post, the waiting time to see the spinal surgeon in a large hospital had risen from 0–62 weeks. A nurse-led assessment clinic was inaugurated to triage patients, cut waiting times and accelerate treatment.

Methods: Referrals were taken directly from general practitioners, and patients triaged using proforma history and examination systems into five categories: mechanical back pain, nerve root entrapment, potentially serious pathology, unknown diagnosis and suitable manipulative therapy.

Audit based on direct patient entry with a light pen interface was integrated into the process. Seventy percent of patients were referred complaining of mechanical back pain, and an Educational Rehabilitation Programme was provided within the clinic.

Results: Following the inauguration of the spinal assessment clinic, waiting times in the consultant clinic fell from 62 weeks to 26 weeks; waiting times in the assessment clinic were between four and six weeks. Emergencies may be seen the same week.

The time from GP referral to surgery for routine nerve root compression fell from 92 weeks to 24 weeks (of which 12 weeks was waiting time for scanning).

Detailed audit of scanning requests in 127 patients demonstrated confirmation of clinical diagnosis in 80 percent of whom half went on to surgery. Of the 20 percent with negative scans, a fifth were subsequently found to have trochanteric bursitis.

An audit of 94 patients revealed reduced analgesic consumption, increased return to work and reduced consultation rates at one year. Five patients were referred to other clinics for further consultation. The satisfaction of the clinic amongst general practitioners was 94 percent. Referrals to the clinic have risen from 403 in 1993 to 1511 in 1999, necessitating the appointment of three further nurse practitioners. Prospective review of 104 patients revealed 95 percent satisfaction rate of the clinic and 67 percent satisfaction rate with rehabilitation. Average low back outcome score increased from 29 to 35 (p< 0.001).

A training programme for nurse practitioners has been established and, to date, ten of the clinics have been inaugurated nation-wide using this model.

Conclusions: A nurse-led clinic for triage of back pain patients has had major impact on waiting times, has produced measurable improvements in patients’ outcome and is associated with high satisfaction ratings in both patients and general practitioners.

Patients with mechanical back pain have been treated in a nurse-led spinal clinic. They attend two one-on-one sessions with a nurse, the second session usually between three and 12 months after the first. Between these visits, they also attended two sets of classes in the spinal assessment clinic to help them improve and manage their back pain. A questionnaire is completed at presentation and at review.

The questionnaires include three scores: The low back outcome Score, MSPQ and the Zung Depression Scale. Since 1995, approximately 2250 patients have been treated. The influence of smoking, gender, age, occupation and marital status on recovery has been studied.

Smoking: Patients who had given up smoking between the first and second questionnaires showed a significant improvement in their outcome score and MSPQ score. Out of 827 who said they smoked on presentation, 280 said they did not on review. From an average outcome score on presentation of 25, those who gave up improved more than those who did not (average score at review 37 vs. 31). A similar trend was seen in the MSPQ averages (from 9 to 7.4 vs. 9 to 8.7). Non-smokers had better results than smokers with an increased outcome score from 30 to 38, MSPQ from 8 to 7.1 and Zung from 20.6 to 19.6. Thus people who gave up smoking showed a larger improvement in their outcome and MSPQ scores than those who continued smoking and those who did not smoke at all.

Gender: Women showed greater improvement in each of the areas than men – 14.5% greater in the outcome score, a 21.2% greater increase in the MSPQ score, and 3.7% in the Zung score.

Age: Patients were divided into 10-year groups. The age group of 50–60 showed the lowest average response for each score, ( 28 to 34 on outcome (average difference = 8), 8.3 to 7.8 on MSPQ (average difference = −0.8), and 21.1 to 21 on Zung (average difference = −0.7). The 30–40 group showed the highest average change on each score (29 to 39 on outcome, 7.9 to 6.9 on MSPQ, 21.8 to 20.1 on Zung). The adjacent age groups showed similar trends but the numbers were not significant.

Occupation: Occupation was divided into eight categories from high-grade professionals to the unemployed. The least improvement was shown by the low-grade occupations (semi-skilled manual workers and the unemployed). The greatest improvements were shown by the middle grade groups. The highest grade occupation showed poor improvement but this was not significant.

Marital Status: For the outcome score, patients who were divorced/separated showed the least improvement, while the married group showed the greatest. On the MSPQ and Zung score, divorced/separated showed the greatest and second greatest improvement (61 % greater than the average on Zung score). The single group showed the worst overall response, scoring the second lowest improvement for the outcome score, the lowest on the MSPQ score (difference −0.47) and their average response actually worsened for the Zung score (from 21 to 21.6).

Conclusion: This study demonstrates that demographic and socio-economic factors significantly influence the level of improvement which patients make in their recovery from mechanical back pain after a treatment program.

Recently a great amount of research has been conducted into fatigability of paraspinal muscles in relation to Lower Back Pain (LBP). Additionally relationships have been observed between a general level of “fitness” and LBP. This research project aimed to evaluate the influence of aerobic fitness and health on lower back muscle function as measured by Electromyographic (EMG) spectral parameters.

Participants undertake a series of psychometric tests, anthropometric data collection, EMG spectral analysis of the paraspinal muscles at lumbar and thoracic regions, and an aerobic fitness test. The EMG test involves a 30-sec isometric pull against a load normalised for weight. The spectral half-width, initial median frequency and median frequency slope are calculated. Participants are given biofeedback and exercise advice.

Participants in this study were of above average fitness level compared to normative data. Other anthropometric data were similar to previous work conducted within this department. Preliminary regression analysis results have revealed no relationships between aerobic fitness level and EMG parameters, a finding that is counter to current beliefs on LBP and fitness, however it was observed that age did significantly influence lumbar spectral variable values (p = .002). A similar psychological profile was observed for all fitness levels.

Due to the disproportionate prevalence of Lower Back Pain (LBP) amongst the socially excluded a Health Action Zone (HAZ) funded population based research project was implemented to evaluate LBP, using EMG spectral analysis, physical fitness and health status amongst this cohort. A large representative sample (n = 300) was required, however the study has been confounded in obtaining its’ prospective sample due to recruitment problems.

Initial recruitment techniques utilised health promotion roadshows held in prominent public locations throughout Teesside and a large-scale media campaign. The ‘roadshows’ promote a positive message relating to LBP and the importance of exercise. Each person receives the opportunity to obtain unique individual information relating to back muscle function from EMG testing as a motivator to participate. Secondary recruitment took the form of purposive sampling amongst selected professional groups (teachers, police, prison officers), testing taking place in the workplace but employing the same research “message”.

The project had been unsuccessful in i) recruiting the general public within the public domain and ii) specifically recruiting the socially excluded. Population based research, especially that which intends to target difficult to access populations may encounter difficulties in recruitment. Why? Distrust and suspicion towards positions of “authority”, low perceived importance of research to this cohort, simple apathy? These reasons are anecdotal and we would be very interested in any ideas and welcome any input on this frustrating issue.

The aim of this study was to compare implementation of RCGP guidelines in patients in Primary Care with acute low back pain between GP and Nurse Practitioner. This report presents preliminary results.

The intention was to recruit 200 patients presenting to GP with new episode of back pain. 50% randomised to NP care, 50% to GP care. Outcome measured by documentation audit and patient feedback. Individuals complete a questionnaire which includes a Low Back Outcome Score (LBOS) at 14 weeks, 6,12 and 24 months. All patients in NP arm given back book and advised against bed rest.

Initial Findings: (n = 145): The LBOS score was identical (30) for the 73 patients randomised to nurse practitioner care and the 72 with routine GP care. There were no significant differences between the scores at 14 weeks and 6 months, with an increase in LBOS to 45–49, but numbers dropping to 28 in the NP group and 26 in the GP group.

Process audit at 14 weeks: Only 10 of NP patients were not given the back book compared with 74% for GP care. 13% of NP patients were prescribed bed rest against 18 for GP care.

Initial results suggest no significant difference in outcome between GP and Nurse Practitioner patients. Of interest is that 10% and 13% of patients failed to recall important features of management. This implies that audit of healthcare processes by patient questionnaire may be unsatisfactory.

The aim of this study was to test the effectiveness of a nurse practitioner-led clinic for managing the pre and postoperative care of patients undergoing lumbar spine surgery, against traditional clinic treatment.

Ninety patients were randomised- 46 (Group 1) attended a nurse practitioner run pre-operative class and post-operative follow-up clinic and 44 (Group 2) were seen by the surgeon before and after the operation. All patients completed the Low Back Outcome Score, MSPQ and Zung score, pre-operatively and at six months post-op.

There were 46 male and 44 female patients, and mean age was 45.4 years (range 20–77). The two groups were demographically similar (p = 0.418). The mean pre-op outcome score was 23.49 in group 1 and 17.41 in group 2 (p = 0.038) and the mean post-op scores were 44.67 and 35.38 for group 1 and 2 respectively (p = 0.021). Intra-group comparison showed an improvement in post-op outcome score for all patients (p = 0.001), but those in group 1 were significantly more satisfied (p = 0.008). Four theatre slots were lost in group 2 but none in group 1.

A nurse practitioner-led pre-op counselling and post-op follow-up is more effective than the traditional clinic attendance for patients undergoing lumbar spine surgery and prevented waste of theatre time.

The results of primary total hip arthroplasty for sub-capital femoral neck fracture in previously normal hips are reported. Thirty-seven patients aged 70 or less at the time of surgery were reviewed at an average follow-up of 56 months. Eighteen (49%) had undergone or were awaiting revision surgery. A further four (11%) had definite radiological signs of loosening. Harris hip scores were calculated and correlated well with the results of gait analysis; these suggested that it was the more vigorous patients that were more liable to early failure. Consequently, primary total hip replacement is not recommended for subcapital fractures in the younger patient without pre-existing hip pathology.

Computerised tomography of the lumbar spine was performed on 22 patients with clinical evidence of prolapse of an intervertebral disc and normal or equivocal radiculograms. Of 11 patients with positive scans who had an operation the presence of pathology was confirmed in 10. Although CT scanning is always helpful in diagnosing disc disorders, where facilities are scarce (as in Great Britain) it is best employed in patients with negative or non-contributory radiculography.

A study of the contamination of suckers used during total hip replacement has been undertaken. Thirty suckers used throughout the operation had their tips cultured: from 11 of these bacteria were grown. The organisms found were those which have previously been implicated in deep infection of total hip replacements. In subsequent operations a further 31 suckers were used for cleaning only the femoral shaft; of these only one was contaminated. This suggests that sucker contamination is related to how long the sucker is in use; consequently it is recommended that a new sucker be used for the preparation of the femoral shaft.