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Competing Interests: No conflict of interest. No financial support.

Claims that a treatment works are hollow unless qualified in terms of: in what respects, by how much, how often, and for how long. Essential co-requisites for improvements in pain are improvements in function, psychological distress, and use of health care. Validated instruments are available for these outcome measures. Mean scores and p-values are not informative. Categorical data are required to reveal by how much a treatment works and how often. In order to provide a full picture, outcomes need to be followed until they plateau. Readers of studies should not rely on what authors claim. Instead, readers should demand comprehensive, transparent data on outcomes so that they can decide for themselves if a treatment works to their satisfaction., (© 2022 The Author.)

For clinical practice to be professionally responsible, any diagnostic tests used need to be valid because, if a test lacks validity the information that it provides is wrong. Of the several subtypes of validity, the crucial one is construct validity, which determines how well a diagnostic test discriminates simultaneously between the presence and the absence of the condition being diagnosed. Its key parameters are the sensitivity and specificity of the test, and its (positive) likelihood ratio. The likelihood ratio serves mathematically as a coefficient in an equation that measures the confidence one can have that a positive result of the test is true-positive, given the prevalence of the condition being diagnosed. There is no ideal value for likelihood ratios that make a diagnostic test worthwhile. The value required depends on how much confidence a physician needs to have in a diagnosis before undertaking treatment, which must be calculated using the likelihood ratio and prevalence of the condition being diagnosed., (© 2022 The Author.)

Studies of pain treatment involve comparing groups. In observational studies scores for outcome variables in the one group are compared before and after treatment. In controlled trials, scores are compared between groups undergoing different treatments. Statistics based on group scores might show that a statistically significant change has occurred but they do not reveal how well a treatment works. That is revealed by categorical data that show the proportion of patients that benefitted by how much after treatment. Those proportions are qualified by the 95% confidence interval of the proportion. In observational studies the magnitude of the success rate, and its 95% confidence interval, is enough to indicate how well the treatment worked. In controlled trials, success rates can be compared to determine how more often is one treatment successful than another. Statistical significance of the difference is established if the confidence intervals of the respective success rates do not overlap, or if the 95% confidence interval of the difference between success rates does not include zero. Pragmatic trials compare one treatment with another, but the comparison does not show if either treatment works well. Each arm of a pragmatic trial constitutes an observational study and the data in each ach show how well each treatment works. Explanatory trials investigate the extent to which the observed success rate is provided by responses to non-specific effects of treatment. The extent to which active treatment is more often effective than is sham treatment can be demonstrated by comparing the success rates of the two treatments, by comparing their survival curves, and by calculating the attributable effect and the number needed to treat of the active treatment., (© 2022 The Author.)

For professional practice to be responsible, any diagnostic tests used must be reliable. Therefore, the reliability of any diagnostic test needs to have been measured. The classical statistic for quantifying reliability is Kappa. Although Kappa can be promptly determined using a programmed calculator, using an algorithm to derive Kappa provides greater insight into what it is actually measuring and why. Kappa scores can be graded, with verbal descriptor applied to different grades. However, those descriptors do not necessarily reflect the degree of skill required to achieve different grades of Kappa. High levels of skill attract high Kappa scores, but Kappa scores described as fair or moderate are not necessarily flattering because they can be achieved with questionable levels of skill. Various corrections can be applied to the calculation of Kappa scores in order to raise their value, and to improve the verbal descriptors of their grade, but these may not be legitimate or necessary. Low Kappa scores do not condemn tests but they serve to raise questions about their reliability., (© 2022 The Author.)

Effect-size is a statistic often used in studies of pain treatment. Its attraction is that numerical values can be translated into adjectives, such as small, medium, and large, that describe the change in scores for outcome measures. However, these adjectives can be misused to imply that the effectiveness of the treatment is the equivalent of small, medium, or large. Consideration of examples reveals the fallacy of this practice. Treatments with little to no effectiveness can produce effect-sizes described as medium or large. Reciprocally, treatments with good but imperfect effectiveness generate effect-sizes described as very large or even huge. Effect-size was developed specifically to describe the magnitude of statistical changes, but has little proportional bearing on effectiveness of treatment. When evaluating treatments, readers should not be swayed by descriptors of effect-sizes. Instead, they should consult categorical data on success rates, upon which they can base their decision as to how well the treatment works., (© 2022 The Author.)

Objectives: The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine., Methods: Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield., Results: In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%., Conclusions: Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Estimates of the prevalence of lumbar zygapophysial joint (Z joint) pain differ in the literature, as do case definitions for this condition. No studies have determined the prevalence of "pure" lumbar Z joint pain, defined as complete relief of pain following placebo-controlled diagnostic blocks., Objective: The objective of this study was to estimate the prevalence of "pure" lumbar Z joint pain., Methods: In a private practice setting, 206 patients with possible lumbar Z joint pain underwent controlled diagnostic blocks using one of two protocols: placebo-controlled comparative blocks and fully randomized, placebo-controlled, triple blocks., Results: In the combined sample, the prevalence of "pure" lumbar Z joint pain was 15% (10-20%)., Conclusions: The prevalence of "pure" lumbar Z joint pain is substantially and significantly less than most of the prevalence estimates of lumbar Z joint pain reported in the literature., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria., Design: Comprehensive systematic review., Methods: A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies., Outcome Measures: The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief., Results: Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used., Conclusions: Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques., Design: Comprehensive systematic review., Methods: A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies., Outcome Measures: The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes., Results: Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique-two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement-resulted in 56% of patients experiencing 100% relief of pain at six months., Conclusions: This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement., (© 2020 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: The editors declare no conflicts of interest in this work. Baogan Peng Nikolai Bogduk Michael J. DePalma Ke Ma

Objectivesbackground: Objectives To determine the extent and strength of evidence that supports the belief that cervical intervertebral discs are a source of neck pain., Design: Design The evidence from anatomical, laboratory, experimental, diagnostic, and treatment studies was summarized and analyzed for concept validity, face validity, content validity, and construct validity., Results: Results Evidence from basic sciences shows that cervical discs have a nociceptive innervation, and experimental studies show that they are capable of producing neck pain. Disc stimulation has been developed as a diagnostic test but has rarely been used in a disciplined fashion. The prevalence of cervical disc pain has not been properly established but appears to be low. No treatment has been established that reliably achieves complete relief of neck pain in substantial proportions of patients., Conclusions: Conclusions Basic science evidence supports the concept of cervical disc pain, but epidemiologic and clinical evidence to vindicate the clinical application of the concept is poor or lacking., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Fracture liaison services (FLS) are an accepted approach to lowering rates of osteoporotic refractures. However, resource allocations to FLS are open to challenge, as most relevant cost analyses are based on anticipated, rather than observed, benefits. To support informed decision making, we have estimated the cost of operating an FLS, from the perspective of the Australian health system, with real life costs. On the basis of hospital records, we compared total costs of two cohorts of patients presenting with minimal trauma fractures (MTFs) at two hospital emergency departments (EDs) across a 6-month period (July to December 2010). The treatment cohort (FLS Cohort, n  = 515) attended an ED at a hospital offering FLS post-fracture care; the Usual Care Cohort ( n  = 416) attended an ED at a hospital without an FLS. Hospital records were reviewed for further attendance of both groups at their respective hospitals' EDs with refractures for the subsequent 3 years. Costs were constructed from "bottom up" with a "microcosting" approach. Total costs for both cohorts included any FLS and the costs of refractures. Cohort costs were estimated for every 1000 patients over the 3 observed years. Compared with the Usual Care Cohort, the FLS Cohort had 62 fewer fractures per 1000 patients and $617,275 lower costs over 3 years. In a sensitivity analysis, where 20% of the Usual Care Cohort received FLS preventative treatment, FLS Cohort costs were lower by $880,154. As both hospitals consistently process around 2000 patients per year, the estimated annual saving is $1.2 million to $1.8 million (Australian dollars). From the perspective of the Australian public health system, investment in FLS can be a financially effective way of reducing the cost of osteoporotic fracture management., (© 2018 The Authors published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.)

Objective Neck-Tongue syndrome (NTS) is characterized by brief attacks of neck or occipital pain, or both, brought out by abrupt head turning and accompanied by ipsilateral tongue symptoms. As the disorder is rare, we undertook a systematic review of the literature to identify all reported cases in order to phenotype clinically the disorder and subsequently inform clinical diagnostic criteria. Methods Two electronic databases were searched using the search term "neck tongue syndrome". All English language references were reviewed in full. Cases were abstracted using a standardized abstraction form and the references of the retrieved articles were reviewed by hand to identify additional references and cases. Conference proceedings from recent headache meetings were searched. We also report six new cases from our centers. Results There were 39 primary cases, 56% of which were female. Mean age (SD) at onset was 16 (12) years. Twenty (53%) experienced neck pain, seven (18%) occipital pain, and 11 (29%) both. Pain was most often sharp or stabbing and severe, lasting several seconds to several minutes. Eleven experienced numbness and/or tingling in the neck/occiput following the pain. Thirty-six had an accompanying tongue sensory disturbance and three a motor/posture disturbance; five had both. Thirteen had other headaches, and four a family history of Neck-Tongue syndrome. Conclusions Neck-Tongue syndrome typically has pediatric or adolescent onset, suggesting that ligamentous laxity during growth and development may facilitate transient subluxation of the lateral atlantoaxial joint with sudden head turning. Familial cases suggest a genetic predisposition in some individuals. Neck-Tongue syndrome should be re-instated in the International Classification of Headache Disorders.

Authors, readers, and editors share a common focus. Authors want to publish their work. Readers want to see high-quality, new information. Referees and editors serve to ensure that authors provide valid conclusions based on the quality of information that readers want.Common to each of these roles are instructions to authors. However, these are typically written in an uninspiring, legalistic style, as if they are a set of rules that authors must obey if they expect to get published. This renders the instructions boring and oppressive, if not forbidding. Yet they need not be so, if they are set in context.Instructions to authors can be cast in a way as to reflect common purpose. They can remind authors what perceptive readers want to see in a paper and, thereby, prompt authors to include all necessary information. If cast in this way, instructions to authors are not a set of rules by which to satisfy publishers; they become guidelines for the etiquette of communication between authors and their readers.Against this background, the present article has been composed to serve several purposes. Foremost, it amplifies instructions to authors beyond the conventional technicalities such as headings, layout, font size, and line spacing. It prescribes the type of information that should be communicated and explains the reasons for those recommendations. Doing so not only informs authors about what to write, but also informs readers and referees about what to look for in a good paper. Secondarily, the article publicizes examples of errors and deficiencies of manuscripts submitted to the Journal in the past that have delayed their acceptance and publication, which could have been avoided had the forthcoming recommendations been followed. The recommendations also reprise the elements taught in courses conducted by the Spine Intervention Society in their extended program on evidence-based medicine. Doing so underscores that instructions for authors are not a procedural technicality but a way to ensure that what authors write, what readers read, and what the Journal publishes comply with contemporary precepts of good evidence.Some 20 years ago, the Journal of the American Medical Association published a comprehensive series of articles with a common title: "Users' Guides to the Medical Literature" [1,2]. These articles focused on the science of statistical tests and critical appraisal, and their importance for properly understanding the literature. The present article differs in that it does not presume to teach technicalities. Instead, it describes and explains, step by step, the critical components of an article, what authors should include, and what readers should look for, so that the Journal can ensure that consistent, high-quality information is shared between its authors and readers.The present article focuses on articles concerning treatment of pain, largely because this type of article is more commonly submitted than articles on reliability or validity of diagnostic procedures. Although the present article principally focuses on papers for the Spine Section of the Journal, the same principles, appropriately adapted, serve for other sections., (© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Guidelines have been published that recommend discontinuing anticoagulants in patients undergoing interventional pain procedures. The safety and effectiveness of these guidelines have not been tested., Objectives: The present study was performed to determine if continuing or discontinuing anticoagulants for pain procedures is associated with a detectable risk of complications., Methods: An observational study was conducted in a private practice in which some partners continued anticoagulants while other partners routinely discontinued anticoagulants., Results: No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths., Conclusions: Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Diagnostic blocks are used in different ways for the diagnosis of spinal pain, but their validity has not been fully evaluated., Methods: Four clinical protocols were analyzed mathematically to determine the probability of correct responses arising by chance. The complement of this probability was adopted as a measure of the credibility of correct responses., Results: The credibility of responses varied from 50% to 95%, and was determined less by the agents used but more by what information was given to patients and if the agents were fully randomized for each block., Conclusions: Randomized, comparative local anesthetic blocks offer a credibility of 75%, but randomized, placebo-controlled blocks provide a credibility of 95%, and are thereby suitable as a criterion standard for diagnostic blocks., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Among other important features of the functional anatomy of the spine, described in this chapter, is the remarkable difference between the design and function of the cervical spine and that of the lumbar spine. In the cervical spine, the atlas serves to transmit the load of the head to the typical cervical vertebrae. The axis adapts the suboccipital region to the typical cervical spine. In cervical intervertebrtal discs the anulus fibrosus is not circumferential but is crescentic, and serves as an interosseous ligament in the saddle joint between vertebral bodies. Cervical vertebrae rotate and translate in the sagittal plane, and rotate in the manner of an inverted cone, across an oblique coronal plane. The cervical zygapophysial joints are the most common source of chronic neck pain. By contrast, lumbar discs are well designed to sustain compression loads, but rely on posterior elements to limit axial rotation. Internal disc disruption is the most common basis for chronic low-back pain. Spinal muscles are arranged systematically in prevertebral and postvertebral groups. The intrinsic elements of the spine are innervated by the dorsal rami of the spinal nerves, and by the sinuvertebral nerves. Little modern research has been conducted into the structure of the thoracic spine, or the causes of thoracic spinal pain., (© 2016 Elsevier B.V. All rights reserved.)

Background: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections., Methods: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process., Results: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration., Conclusion: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Background: In the absence of a suitable reference standard, diagnostic local anesthetic blocks cannot be validated in the manner conventionally used for diagnostic tests. Consequently, diagnostic blocks are vulnerable to criticism for lacking validity, or being "not proven.", Study Design: Philosophical essay., Methods: Inspired by the "viewpoints" proposed by Bradford Hill for testing cause and effect in epidemiology, a set of axiomatic criteria was developed with which the validity of diagnostic blocks could be assessed., Results: Eight criteria were established: plausibility, experiment, target-specificity, effect, duration, consistency, control, and replication. Applying weighted scores to these criteria produces a metric by which the validity of a particular diagnostic block can be quantified., Conclusion: The eight criteria provide an axiomatic, philosophical basis for diagnostic blocks in general, and serve to show what empirical evidence needs to be gathered in order to validate a particular block. The associated metric allows the scientific evidence for different blocks to be quantified and compared., (Wiley Periodicals, Inc.)

Cervicogenic headache is pain referred to the head from a source in the cervical spine or mediated by cervical nerves. Clinical features allow for no more than a diagnosis of probable cervicogenic headache. Definitive diagnosis requires evidence of a cervical source of pain. For most treatments, the evidence is limited or poor. Many patients with probable cervicogenic headache can be managed with exercise therapy, with or without manual therapy. Intractable cervicogenic headache can be investigated with controlled diagnostic blocks of the upper cervical joints and treated with thermal radiofrequency neurotomy. Other interventions are experimental or speculative., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The aim of this study was to determine the extent to which patients with hip and knee osteoarthritis (OA) referred for orthopaedic consultation at a large Australian public hospital reported using conservative management strategies as recommended by current practice guidelines. A therapist-assisted questionnaire was employed within the context of a standard physiotherapy assessment in a consecutive cohort of patients with hip or knee OA. Two hundred and two patients with hip or knee OA comprised the included sample. Thirty-nine percent (n=79) reported having only previously consulted their general practitioner. Only 20% (n=41) felt that they had been sufficiently educated about the diagnosis, their treatment options and prognosis. Thirty-three percent (n=66) had not previously engaged in any non-pharmacological management strategy considered a core clinical practice guideline recommendation. The findings of this study suggest that several inconsistencies may exist between current Australian clinical practice and OA clinical guideline recommendations. Identification of the barriers to the use of conservative management requires timely investigation coupled with a national implementation framework to support the translation of guideline recommendations into practice.

Objective: To determine the effectiveness and safety of computerized tomography (CT) guided, lumbar transforaminal injection of steroids in the treatment of radicular pain., Design: Systematic review of published literature., Interventions: Two reviewers independently assessed 19 publications on the effectiveness and safety of CT-guided, lumbar transforaminal injection of steroids., Outcome Measures: For effectiveness, the primary outcome was the success rate for relief of pain. For safety, the radiation exposure involved and the nature of complications were determined., Results: Much of the literature fails to provide evidence. Two studies reported decreases in mean or median pain scores but no other data. Two studies reported success rates of between 34% and 62% for achieving 50% relief of pain at between 1 and 6 months after treatment. CT-guided injections may involve greater radiation exposure than does fluoroscopy-guided injections and do not avoid catastrophic spinal cord injury., Conclusion: The evidence-base for CT-guided lumbar transforaminal injection of steroids is meagre. This intervention is not more effective than fluoroscopy-guided injections and is not demonstrably safer., (Wiley Periodicals, Inc.)

The concept of cervical disc arthroplasty (CDA) for the anterior treatment of cervical pathology has existed for approximately half a decade. In this time, multiple devices have been developed for this purpose, with the ultimate aim to provide an alternative to fusion. Fifty-five patients with cervical spondylotic radiculopathy and myelopathy underwent CDA over a 5 year period. Data was collected on 46 patients, which included Visual Analogue Scale scores for neck pain and arm pain, Neck Disability Index scores, Short Form-36 v2 (SF-36) and Nurick grades for myelopathy patients. Preoperative data and data obtained at the latest clinical follow-up (median 48 months, range, 10-76 months) were analysed to assess the intermediate term efficacy of the procedure. In patients with radiculopathy, arm pain improved by 88% (p<0.001). In those presenting with myelopathy, the Nurick grades improved from a median of 1 to 0 (p<0.001). In both groups of patients, improvements in pain and neurologic deficit were accompanied by significant improvements in multiple domains of the SF-36. Using a composite system which considered neck pain, arm pain, function and myelopathy, we arrived at an overall success rate of 73%. We concluded that CDA is an effective intervention for improving neurologic deficit, arm pain and local neck symptoms that translated into improvements in physical and social functioning in the intermediate term., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The aim of this project was to investigate the reliability of a new 11-item quality appraisal tool for studies of diagnostic reliability (QAREL). The tool was tested on studies reporting the reliability of any physical examination procedure. The reliability of physical examination is a challenging area to study given the complex testing procedures, the range of tests, and lack of procedural standardisation., Methods: Three reviewers used QAREL to independently rate 29 articles, comprising 30 studies, published during 2007. The articles were identified from a search of relevant databases using the following string: "Reproducibility of results (MeSH) OR reliability (t.w.) AND Physical examination (MeSH) OR physical examination (t.w.)." A total of 415 articles were retrieved and screened for inclusion. The reviewers undertook an independent trial assessment prior to data collection, followed by a general discussion about how to score each item. At no time did the reviewers discuss individual papers. Reliability was assessed for each item using multi-rater kappa (κ)., Results: Multi-rater reliability estimates ranged from κ = 0.27 to 0.92 across all items. Six items were recorded with good reliability (κ > 0.60), three with moderate reliability (κ = 0.41 - 0.60), and two with fair reliability (κ = 0.21 - 0.40). Raters found it difficult to agree about the spectrum of patients included in a study (Item 1) and the correct application and interpretation of the test (Item 10)., Conclusions: In this study, we found that QAREL was a reliable assessment tool for studies of diagnostic reliability when raters agreed upon criteria for the interpretation of each item. Nine out of 11 items had good or moderate reliability, and two items achieved fair reliability. The heterogeneity in the tests included in this study may have resulted in an underestimation of the reliability of these two items. We discuss these and other factors that could affect our results and make recommendations for the use of QAREL.

Objective: To test the null hypotheses that: lumbar intervertebral discs cannot be a source of pain; discs are not a source of pain; painful lumbar discs cannot be diagnosed; and there is no pathology that causes discogenic pain., Methods: Philosophical essay and discourse with reference to the literature., Results: Anatomic and physiologic evidence denies the proposition that disc cannot be a source of pain. In patients with back pain, discs can be source of pain. No studies have refuted the ability of disc stimulation to diagnose discogenic pain. Studies warn only that disc stimulation may have a false-positive rate of 10% or less. Internal disc disruption is the leading cause of discogenic pain. Discogenic pain correlates with altered morphology on computerized tomography scan, with changes on magnetic resonance imaging, and with internal biophysical features of the disc. The morphological and biophysical features of discogenic pain have been produced in biomechanics studies and in laboratory animals., Conclusions: All of the null hypotheses that have been raised against the concept of discogenic pain and its diagnosis have each been refuted by one or more studies. Although studies have raised concerns, none has sustained any null hypothesis. Discogenic pain can occur and can be diagnosed if strict operational criteria are used to reduce the likelihood of false-positive results., (Wiley Periodicals, Inc.)

Objective: This study aims to determine the effectiveness of lumbar medial branch radiofrequency neurotomy (RFN) performed by two practitioners trained according to rigorous guidelines., Design: Prospective, outcome study of consecutive patients with chronic back pain treated in a community setting., Interventions: A total of 106 patients, selected on the basis of complete relief of pain following controlled, diagnostic, medial branch blocks, were treated with RFN according to the guidelines of the International Spine Intervention Society., Outcome Measures: Successful outcome was defined as complete relief of pain for at least 6 months, with complete restoration of activities of daily living, no need for any further health care, and return to work. Patients who failed to meet any of these criteria were deemed to have failed treatment., Results: In the two practices, 58% and 53% of patients achieved a successful outcome. Relief lasted 15 months from the first RFN and 13 months for repeat treatments. Allowing for repeat treatment, patients maintained relief for a median duration of 17-33 months, with some 70% still having relief at follow-up., Conclusion: Lumbar RFN can be very effective when performed in a rigorous manner in appropriately selected patients. Chronic back pain, mediated by the lumbar medial branches, can be stopped and patients fully restored to normal living, if treated with RFN., (Wiley Periodicals, Inc.)

Background: Although posterior lumbar interbody fusion (PLIF) is regarded as an effective treatment for spondylolisthesis, few studies have reported comprehensive, long-term outcome data, and none has investigated the incidence of deterioration of outcomes., Objective: To determine and compare the success rates and long-term stability of outcomes of open PLIF and minimal-access PLIF in the treatment of radicular pain and back pain in patients with spondylolisthesis., Methods: Forty-three patients were followed for a minimum of 3 years. They completed a Short-Form Health Survey and visual analog scores for back pain and leg pain and underwent lumbar spine radiography. Outcomes were compared with baseline data and 12-month data., Results: Surgery succeeded in reducing listhesis and increasing disc height, but had little effect on lumbar lordosis or the angulation of the segment treated. At 12 months after surgery, listhesis was reduced, disc height was increased, leg pain was reduced or eliminated, and physical functioning restored. Back pain was less often relieved. These outcomes were largely maintained over the ensuing 2 years. Only 5% to 10% of patients reported deterioration in their relief of pain. Depending on the definition adopted for success, the long-term success rate of PLIF may be as high as 70%., Conclusion: For the relief of leg pain, the success rates of open PLIF (70%) and minimal-access PLIF (67%) for spondylolisthesis are high and durable in the long-term. PLIF is less often successful in relieving back pain, but the outcomes are maintained. The outcomes of open PLIF and minimal-access PLIF were statistically indistinguishable., Abbreviations: MCIC, minimally clinically important changeMPLIF, minimal-access posterior lumbar interbody fusionOPLIF, open-access posterior lumbar interbody fusionPLIF, posterior lumbar interbody fusionSF-36, Short-Form Health Survey.