Arthritis Research UK
Orthopaedic Clinical Studies Group: Spine
BASS / BSS / SBPR Agenda
Introduction
Spinal conditions are very common and are largely treated non-operatively. The annual incidence of
low back pain is approximately 30-40% and the prevalence of symptomatic lumbar disc herniation is
approximately 2%. Thankfully both these conditions have an excellent natural history.
Spinal surgery is performed by both Orthopaedic Surgeons and Neurosurgeons and the Orthopaedic
Clinical Studies Group represents both sub-specialities for the purpose of spinal research. The spinal
conditions of relevance to ARUK include:
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Degenerative conditions
Deformity
Infection
Trauma
There already exists a ‘Musculoskeletal Pain Disorders Studies Group’ which includes a research
agenda for the conservative management of spinal conditions. The Executive Committees of the
three Spinal Societies have considered the research priorities in each of the above areas and the
following agenda lists areas considered to advance knowledge or improve patient care in surgical
procedures, basic science related to surgical pathology, and rehabilitation around surgical
conditions. Research grants are available for all aspects of research into spinal conditions where the
condition is either primarily degenerative or may lead to a degenerative condition. However,
preference will be given to projects which address the key areas of research identified in the
categories below.
All aspects of spinal research methodology will be considered including basic science, epidemiology
and clinical research. For clinical studies, randomised, prospective studies must address a
particularly important question. Prospective cohort studies, especially involving multi-centres with
good evaluation of outcomes will be considered.
The British Association of Spine Surgeons (BASS) are producing a National Spine Registry which will
be non-mandatory, free to all users and allow different ‘levels’ of data collection depending on the
surgeon’s enthusiasm and available local resources. Data can be collected on all spinal conditions
including degenerative, deformity, trauma, tumour and infection. The data collected will include:
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Diagnosis
Additional details including neurological deficit
Operative details
Complications
Patient Reported Outcome Measures (PROMs)
The Registry will also provide a mechanism for data collection in approved research studies
especially where these are multi-centre or involve PROMS.
1. Spinal Degenerative Disease
Degenerative change in the cervical and lumbar spine can result in ‘axial’ pain, localised to the
neck or low back. Nerve root compression either from a disc protrusion or secondary to
degenerative change can result in radiculopathy (pain and/or weakness) in upper or lower limbs.
Compression of the central neurological structure can produce symptoms of spinal cord
compression which can be slow onset (cervical myelopathy) or occasionally of rapid onset or
symptoms of cauda equina compression which can also be of slow onset (lumbar spinal stenosis)
or rapid onset (cauda equina syndrome).
These problems affect a large number of patients each year with about 30-40% experiencing
significant back pain lasting more than 24 hours each year. It was estimated in 2000 that
approximately £1.6 billion is spent treating back problems. On average 1% of the working
population are on sick leave due to back pain on any one day resulting in 5 million lost working
days at a cost to business of £600m. In the UK in 2002, it was estimated that the cost of back
pain was 1-2% of GDP.
Key directions of future research:
 Basic science:
o
Evaluation of disc degeneration and regeneration.
o
Chemical mediation of radicular pain.
 Epidemiology:
o
Natural history of degenerative conditions including degenerative or lytic
spondylolisthesis and lumbar spinal stenosis.
o
Evaluating cohorts with the same initial symptom to determine an optimal care
pathway both in terms of patient outcome and economic analyses with the aim
of improving quality of life for the most number of patients in the most
economic way.
 Non-surgical management (where patients can be recruited in spinal surgical clinics):
o
Is physiotherapy beneficial in acute lumbar radicular pain (NIHR funded pilot
study 2011)?
o
Is physiotherapy beneficial in lumbar spinal stenosis?
o
Prognostic factors in acute low back pain and acute cervical/lumbar radicular
pain.
 Surgery:
o
How to measure surgical outcomes.
o
Studies to enhance our knowledge of improving overall outcome with improved
patient selection.
o
Evaluation of new treatment methods.
o
Effect of different surgical techniques / approaches on outcome eg:
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In lumbar discectomy should we just remove the compressing fragment
or perform an aggressive disc clearance?
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Bone graft substitutes versus iliac crest bone graft (cost-effectiveness).
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In non-resolving cervical radicular pain should we do an anterior cervical
discectomy and fusion or a cervical disc replacement?
o
Prognostic indicators of surgical outcome eg are selective nerve root injections
prognostic in the outcome of lumbar/cervical decompression surgery in cases
with equivocal symptoms or MRI scan?
o
Influence of rehabilitation before and/or after surgical procedures on the
outcome of spinal surgery.
o
Exploration of care pathways and patient needs in relation to surgery.
2. Deformity
Idiopathic scoliosis in childhood (infantile, juvenile and adolescent idiopathic scoliosis) is thought
to be associated with an increased risk of back pain in adult life with surgery of unproven benefit
in reducing this risk.
Degenerative scoliosis is a de-novo scoliosis usually in the lumbar spine secondary to
degenerative change in the lumbar facet joints and intervertebral discs. Patients present with
any combination of lumbar pain, radicular pain and deformity with frontal and sagittal plane
imbalance. With an aging population, the incidence is increasing but as with other types of
scoliosis, the incidence varies with curve severity. The options for conservative management are
currently limited. Surgery achieves good deformity correction and prevents curve progression
and has very good success at relieving radicular pain but only moderate success at improving
lumbar back pain. The risks of scoliosis surgery in this elderly population are high with
complication rates of over 70%.
All studies of scoliosis should define which curve types and curve sizes are included in the study.
Key directions of future research:
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Basic science:
o
Finite element modelling of deformity progression.
o
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Biomechanical evaluation of surgical methods of spinal deformity correction
including implant design.
Epidemiology:
o
Long-term natural history of treated and untreated adolescent idiopathic
scoliosis eg does surgical correction improve low back pain long-term in
thoracolumbar adolescent idiopathic scoliosis.
o
Natural history of untreated degenerative scoliosis.
Non-surgical management:
o
Brace treatments for adolescent idiopathic scoliosis.
o
Evaluation of new treatment methods.
o
Exercise therapy for adolescent idiopathic scoliosis (HTA study 2011).
Surgery:
o
Operative treatment of adolescent idiopathic scoliosis aiming to reduce longterm disability.
o
How to measure surgical outcomes in scoliosis.
o
Evaluation of new treatment methods.
o
Studies to enhance our knowledge of improving overall outcome with improved
patient selection in degenerative scoliosis.
o
Effect of different methods of surgical techniques / approaches on long term
outcome in degenerative scoliosis eg stopping at L5 versus S1, unilateral fusions
to support exit foramen decompressions.
o
Importance of sagittal balance in degenerative scoliosis and techniques to most
safely achieve acceptable alignment.
o
Influence of rehabilitation before and/or after surgical procedures on the
outcome of spinal surgery.
3. Infection
Spinal infections are considered to be rare but hospital MDTs have shown that these cases are
under the care of numerous departments within the hospital and are therefore more common
that generally believed. Diagnosis is often delayed as patients present with back pain which is a
very common symptom. Once diagnosed (usually on MRI), a successful non-surgical outcome is
thought to be more likely if the infecting organism can be identified on blood cultures or biopsy
and treated with appropriate antibiotics for a prolonged period. Surgical procedures are
uncommon but when needed are usually performed in very unwell patients and complication
rates are high.
Key directions of future research:
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Basic science:
o
Evaluate the products of staphylococcus aureus that seem to promote spinal
fusion.
o
Techniques to improve microbiology yield from biopsies.
Epidemiology:
o
Disease burden.
o
Natural history.
o
Prognostic factors eg microbiology, radiological and MRI predictors of
progressive bone destruction requiring surgical stabilisation.
Non-surgical management:
o
Optimal antibiotic regime for different types of infection including route of
administration and length of time.
o
Effect of diet on outcome.
Surgery
o
Studies aimed at improving our knowledge of early clinical and radiological
indicators for operative intervention.
o
Effect of different methods of surgical techniques / approaches on outcome eg
posterior stabilisation versus posterior stabilisation and decompression versus
posterior stabilisation and anterior decompression.
4. Trauma
Spinal trauma is common and is often managed conservatively. We are unsure how our
management affects long-term outcome.
Key directions of future research:
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Basic science:
o
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Biomechanics of
reconstruction.
unstable
fractures
with
relation
to
stability
Epidemiology:
o
Is adjacent disc damage relevant in the management of vertebral fractures.
after
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Non-surgical management:
o
Necessity for and length of time of brace treatment in thoracolumbar fractures.
o
Role of early physiotherapy in the management of stable thoracolumbar
fractures.
Surgery:
o
Effect of different methods of surgical techniques / approaches eg minimally
invasive stabilisation v open stabilisation, necessity for spinal fusion.
o
Prognostic factors eg the effect of sagittal balance on surgical decision making.
o
Early operative management versus conservative management of type II
odontoid fractures in the elderly.
o
Does physiotherapy improve the long-term outcome after surgical stabilisation
of vertebral fractures?
o
The management of post-traumatic kyphosis.