Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development.

BACKGROUND: There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking. AIM: To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial. METHOD: The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention. RESULTS: In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians' communication skills, during the consultation, in reference to listening skills, validation of patients' pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients' clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management. CONCLUSION: The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients' perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.

Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain.

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). Methods: An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results: There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion: This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK.

Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom.

BACKGROUND: Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification. METHODS: To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers. RESULTS: A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years' experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery. CONCLUSION: This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist.

'Reassurance and healthcare seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study'.

BACKGROUND: Guidelines recommend self-management for most people living with persistent musculoskeletal low back pain (PMLBP) when surgery is ruled out. Conveying this message to patients can be challenging. This study examined patients' perceptions of reassuring communications from surgical spine team practitioners attempting to deliver this message in a single consultation. METHODS: Pre-consultation baseline measures included levels of pain, disability and previous consultation history. Patients' perceptions of reassuring communications were measured within 1-week post-consultation. The outcome variables, measured at 3-month follow-up, included patients' report of subsequent GP visits for back pain, the number of other healthcare providers consulted for back pain and distress. RESULTS: Data from 296 patients (9.8% loss to follow-up) were analysed using hierarchical regression models, controlling for demographic, clinical and study-related factors. In each model, perceived reassurance accounted for a small but significant variance, above and beyond other predictors. Further GP visits were predicted by disability at baseline and perceived reassurance (adjusted R2 of 14.6%). Subsequent consultations with any healthcare professionals were predicted by a shorter duration of back pain, disability at baseline and perceived reassurance (adj. R2  = 10.6%). Distress was predicted by older age, disability and reassurance (adj. R2  = 59.5%). CONCLUSION: Findings suggest that better communication in consultations with orthopaedic spine clinicians might help reduce unnecessary subsequent healthcare utilization and distress. SIGNIFICANCE: Low back pain patients' perceptions of their communication with orthopaedic spine practitioners are associated with subsequent healthcare seeking and distress at follow-up. This study examines the intersection of two important but fairly neglected areas in the pain research: provider communication and patient healthcare utilization.

Taking patients to the ice cream shop but telling them that they cannot have ice cream: a qualitative study of orthopaedic spine clinicians' perceptions of persistent low back pain consultations.

OBJECTIVE: This study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings. SETTING: Secondary care sector in the UK. PARTICIPANTS: Semi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians' perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS: Two meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients' expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues. CONCLUSION: The findings highlight clinicians' perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients' needs in circumstances where surgery is not indicated.

Discharged and dismissed: A qualitative study with back pain patients discharged without treatment from orthopaedic consultations.

BACKGROUND: Consultation-based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment. METHODS: Semi-structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed. RESULTS: Most patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self-management. These behaviours group into four domains: "Knowing my whole story" (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), "Seeing the right person" (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), "Nothing to worry about" (reducing generic reassuring statements but increasing validating statements recognizing suffering) and "Getting to grips with my problem" (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self-manage, reported distress, anger and intention to re-consult. CONCLUSION: Effective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered. SIGNIFICANCE: This study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self-management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation-based reassurance in orthopaedic spinal care settings.

Supplementary stabilization with anterior lumbar intervertebral fusion--a radiologic review.

STUDY DESIGN: A radiologic assessment of the success of anterior lumbar interbody fusion (ALIF) using thin-section computerized tomography (CT) was performed. OBJECTIVE: To assess the effect of different types of posterior stabilization on the fusion rate of ALIF. SUMMARY OF BACKGROUND DATA: Thin-section CT has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiologic methods. Cadaveric studies have shown that posterior stabilization would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. To our knowledge, the results of thin-section CT of ALIF, with and without posterior stabilization, has not been reported previously. METHODS: Patients with discogenic back pain confirmed by diskography underwent ALIF surgery, either as a stand-alone procedure or with posterior stabilization, using translaminar, unilateral pedicle, or bilateral pedicle screws. The 4 cohorts were followed up prospectively, and thin-section CT was used to assess interbody fusion. RESULTS: The fusion rate for stand-alone ALIF was 51%, for patients with supplementary stabilization with translaminar screws 58%, with unilateral pedicle screws 89%, and with bilateral pedicle screws 88%. A significant difference in the fusion rate was found when ALIF was combined with pedicle screw stabilization (P < 0.01). CONCLUSION: The addition of pedicle screw fixation at ALIF produces a significant increase in the rate of interbody fusion.