Background. Chronic pain (CP) accounts for 10–16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives. To describe patients with CP attending the ED and identify factors contributing to their visit. Methods. We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results. Fifty-eight patients  completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions. Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED. Chronic pain (CP) is defined as pain that persists for more than 3 to 6 months or beyond the normal healing time  and it aTo effect solutions for patients with chronic pain who use the ED, we first need to understand who they are, the factors contributing to their presentation, and their opinion on how to improve their pain and functioning. Previous studies have examined physician and ED staff attitudes towards patients with chronic pain , barrierWe used a mixed-methods study design and administered a series of validated questionnaires as well as semistructured interviews to a convenience sample of patients with chronic pain who presented to the ED during the months of July and August 2013. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The study was approved by the Ottawa Health Science Network Research Ethics Board (OHSN-REB).Participants were recruited through the two EDs of the Ottawa Hospital , a large Canadian academic tertiary care centre  with approximately 166,000 annual visits .To be eligible for the study, participants had to be 18 years of age or older, English or French speaking, with a primary complaint of pain meeting our predefined criteria for chronicity. The pain could be constant  or recurrent  but had to have been present for longer than three consecutive months. Patients were excluded if they had communication barriers, had a medical condition listed as critical, had suffered an assault, had evidence of acute intoxication, or were unable to provide consent.ED staff and physicians identified patients meeting the inclusion criteria during thirty ED shifts. These shifts were randomly selected using computer-generated random numbers. Patients who met inclusion criteria were informed of the study by ED staff at the time of their visit. One of two senior anesthesiology residents (JN or ST) from the research team met with patients who expressed interest in participating in the study to give further details and obtain informed consent before conducting the interviews and collecting the survey data. This was done while the patient was waiting to be seen by the ED physician. Interviews generally lasted between 10 and 30 minutes.The following demographic information was collected: age, sex, ethnicity, education level, employment status, number of people in home, family income, healthcare problems, current medications, and health insurance. Interviewers used a semistructured interview format and open-ended questions to elicit participants' perspectives on their primary pain problem and the circumstances surrounding their visit to the ED. After the interviews, patients completed the following instruments: Brief Pain Inventory (BPI) , the PaiAll the data collection was performed by the same two anesthesiology residents who obtained informed consent from participants. They were not involved in the care of the patients. The residents both had prior research experience and participated in study-specific training that involved discussions of qualitative research and interviewing. The interview preceded the administration of the questionnaires to avoid undue influence on patients' responses to the interviews.Demographic characteristics of patients with chronic pain were described using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Indicators of health services utilization  were described using mean and standard deviation, as well as range, median, and interquartile range (Q1–Q3) to account for skewness. All statistical analyses were performed using the software Statistical Package for the Social Sciences version 20 . At thisThe audio-recorded interview data were transcribed verbatim, checked, and entered into NVivo 10 , a qualiSixty-five patients meeting inclusion criteria were referred to the study, of whom 58 (89%) agreed to participate and completed the entire study. This accounts for approximately 2.5% of all patients registered in the ED during the included shifts. Descriptive characteristics of participants can be found in Participants were predominantly Caucasian (79%), middle aged , and women (66%), with at least some college or university education (71%). They had, on average, been living with chronic pain for 5 years (Q1–Q3 = 2.4 to 13.0 years) and reported moderate or severe levels of pain intensity  and pain interference .The most commonly cited reasons for visiting the ED were inability to cope with pain (60%), worry about what was causing the pain (16%), or receiving advice from a physician (10%). Forty-nine (85%) of the 58 participants had a primary care provider who they had visited, on average, 10.2 times  over the previous 12 months. Forty-six participants (79%) had visited the ED for the same problem in the previous 12 months , with one participant having visited the ED 55 times. Sixteen (27%) participants had been hospitalized for their pain in the past 12 months, with one participant having 20 admissions for chronic pain . Forty-two (72%) participants were taking opioids see .n = 31) of participants reported a history of physical, sexual, or emotional abuse. Thirty-six (62%) participants scored within the range of moderate to severe depression, 25 (43%) participants reported moderate or severe anxiety, 28 (48%) participants reported symptoms suggesting posttraumatic stress disorder, and 23 (40%) scored above the cut-off predicting risk of aberrant drug-related behaviours as assessed by the SOAPP-R questionnaire , arthritis (28%), hypertension (28%), and diabetes (20.7%). Seventy-two percent (72%) had seen other physicians including cardiology, gastroenterology, neurology, neurosurgery, gynecology, and urology looking for a remediable cause and treatment for their chronic pain. Six (10%) participants had seen a pain specialist at some point for their chronic pain.When asked to choose from a list of potential options for better chronic pain management, 30 (52%) participants were interested in more effective medications, 27 (47%) participants were interested in having a healthcare professional explain their pain, and 23 (40%) were interested in a referral to a pain clinic. There was also some interest in an exercise/rehabilitation program (21%), surgery (19%), counselling/peer support/nondrug approach (14%), and decreasing or stopping medications (5%).A thematic analysis of the interview transcripts revealed several important themes concerned with both the participants' chronic pain and their experience in the ED. The following are quotes from participants within each theme.Thematic Analyses: Quotes from Participants' InterviewsUncontrollable PainIt gets to the point where it feels like I'm going to die sometimes.It was unbearable.…once it gets too bad, and I have to double on the pills that's it, I have to come in.Last night it was continuous pain. I couldn't sleep, so I said to my husband, ‘I think I better go to the emerg.'Inability to FunctionI couldn't keep nothing down today, and my husband was literally freaking out because I had no liquids today… My migraine headaches are really bad, and when they're bad, I can't keep anything down … So that's why I'm here.I got a headache and I couldn't see. I get up to walk and I was stumbling around.I was going to get back on the sofa, and I couldn't move, couldn't move at all, my legs, my arms…The ambulance had to come and they got me on a stretcher.Limited Primary Care Provider Effectiveness and AccessibilityHe's just basically giving me meds and not trying to fix the problem.I don't think she's doing everything that she can.I find my doctor unsympathetic … When I went to her, she didn't want to listen to me talking about the pressure around my ear. She said to me, ‘For this session, that's all I have the time for,' and I haven't been called back … And there was no talk of pain management or anything. So I thought to myself that I can't rely on her.Seeking AnswersI just want to know what's going on and what I can do, like what they could do … I just want to know what I have and deal with that. Everything is numb. What am I waiting for? What do I have, cancer or what? ‘Cause my doctor told me I might have cancer. If I have cancer, at least I gotta know what I have. Seeking Pharmacological TreatmentUm, basically I have chronic pain all of the time, and there was a mix up with one of my prescriptions and basically, I'm without any pain medication now. Usually I have certain medications that I take. But then after a certain amount, I'm no longer allowed to take it, so I have to come to the emergency because first, the medication is not working, and second, I feel so nauseated that I can't continue to do my daily routine, so I really need to get something fast, like an IV.Feeling Invalidated or Labelled as Drug Seeking in the Emergency DepartmentAnd I said, like, ‘Ow, ow, ow,' you know. And he said, ‘Well, you're not crying or screaming bloody murder, so I don't think you have fibromyalgia.I said I'm not here for a prescription. I'm not. I'm just here to get the back pain under control. And he [the physician] just walked out. I kept showing them, “This is the bottle of morphine prescribed back in May. Look! It's almost all here. I'm not taking it.” Like I felt I had to defend … I was very insulted.unbearable,” “overwhelming,” and “uncontrollable,” often leading to feelings of desperation. As a result, many participants stated that they were “not able to cope” with their chronic pain and believed there were no other options available but to present to the ED. In addition to uncontrollable pain, patients reported a high degree of pain interference leading to an inability to sleep, eat, or walk that prompted them to come to the emergency department. When asked about their primary care providers, the majority stated that they had a provider that they felt comfortable discussing their pain problems with, but they noted limited time availability  or limited emotional availability. Many also reported that their primary care physician was not effective in managing their pain. Some patients also reported that they had decided to visit the emergency room to access pharmacological treatment  or to seek answers about the cause of their pain problem, fearing that something serious might be underlying their pain. Finally, although this experience was not universal, several patients commented on their actual experience accessing the emergency room for their pain problem and reported feeling invalidated or labelled as a drug seeker.The most frequently cited motivation for attending the ED was uncontrollable pain. Patients described their pain as “The objective of this study was to understand factors contributing to the use of the ED for chronic pain, to describe the medical and psychosocial characteristics of patients with chronic pain who use the ED, and to inquire about patients' perspective on potential alternatives to ED visits.The most common reason why study participants visited the ED was inability to cope with their pain. This was reflected in both the patient interviews and the survey responses. Insufficient coping has been associated with increased pain, depression, disability, and poor psychological adjustment . A lack Participants suffered from mental health problems at a rate significantly higher than that reported in the general population, as found in other studies , 42. MorSubstance use-related issues are another potential factor driving ED visits; while the instrument we used is not a diagnostic tool for an opioid-use disorder, 40% of the participants scored in the clinically relevant range suggesting a risk of opioid aberrancy. This is important given that 72% of the patients seen were on opioids and that some patients shared with the interviewer that they came to the ED for prescription renewals even though this is against the policy of the ED where the study was conducted.It is interesting that mental health problems did not emerge as a theme in the interviews and may reflect patients' fear that their pain could be deemed “psychological.” Alternatively, it may represent a lack of awareness of the role that anxiety, depression, trauma, and addiction play in chronic pain. Unrecognized and untreated mental illness can significantly impede successful rehabilitation of chronic pain patients . Mental More than half of our participants had at least three medical comorbidities. It is challenging for healthcare professionals in the ED with limited time and incomplete medical and medication histories to identify and prioritize the relative contributions of medical issues, mental health, and substance dependence to the chronic pain complaint. There are safety concerns as well because prescribing opioids for chronic pain in the ED without a thorough knowledge of the patient may increase the risk of adverse drug-related events and complications, including death , 48.In contrast to previous studies showing an association between ED use and lack of access to a primary care physician , we founFinally, we found that chronic pain patients who present to the ED are generally interested in other methods to better manage their symptoms. Although the majority of participants (52%) stated they were most interested in more effective medications to manage their pain, 40% of the participants were interested in being referred to a pain clinic and 47% were interested in having a health professional explain their pain condition to them. It would be beneficial to explore and test these options in a focused program for patients who frequently visit the ED for their chronic pain; some options include rapid access to education about pain, self-management training, and interventions designed to address depression, insomnia, and anxiety which may have a beneficial impact on patient pain experience and function.Our study has several limitations. The most important ones are that we did not set out to select a probability sample, that our sample is small, and that we only recruited patients from one hospital. We were able to interview, on average, 2 patients with chronic pain per ED shift. Given that, at our institution, 10.4% of patients presenting to the ED do so for a chronic pain problem  and thatAnother limitation is that we elicited patients' perspective on potential alternatives to ED visits through a checklist of items that were derived from clinical interactions with patients. Other strategies to elicit information could involve a focus group that would provide opportunities to discuss pros and cons and applicability and potentially come up with other creative ideas to implement and evaluate.Finally, we had a higher than average number of female, well-educated Caucasians. Chronic pain is more prevalent among women and women are less likely to have pain optimally treated . There aOur study has demonstrated that even though the majority of participants were, in fact, under the care of a primary care provider, they still chose to come to the ED for their pain problem. It appears that their complex pain, medical, and psychosocial needs are not being met within the community. Further research is needed to understand the nature of the relationship between the patient and their primary care provider and to identify and address possible barriers that prevent patients from seeking help for their pain problem from them. We also need to examine how primary care physicians could become more effective in addressing chronic pain in their practice as well as what resources are required to meet the needs of patients in the community. This could include improving access to evidence-based interventions for chronic pain including cognitive-behavioural therapy, mindfulness-based programs, support groups, self-management programs, or interdisciplinary management to improve clinical outcomes and reduce acute care use among patients with chronic pain.Further work is also required to identify the biopsychosocial characteristics of patients in other centres to examine regional differences if there are any. Focusing also on patients with chronic pain who are heavy users of the ED may allow opportunities to design effective interventions that have the potential to not only improve clinical outcomes but also reduce healthcare costs. There is also an urgent need to evaluate different strategies for addressing chronic pain in the ED. This could be accomplished by providing more training for ED physicians on chronic pain and substance use disorders and their treatments as well as addressing factors contributing to nonadherence to guidelines surrounding the use of opioids in chronic noncancer pain. Having ED physician better prepared to care for patients with chronic pain may improve the experience of physicians, staff, and patients and lead to better clinical outcomes and rational use of urgent care resources. However, solving the issue of chronic pain in the ED requires the involvement of all interested stakeholders and we believe that an important step in this work is to bring together patients, clinicians, caregivers, and decision-makers to come up with solutions that will lead to an improved health system.Patients with chronic pain require more than what the emergency department can offer. What is unique to this investigation, benefitted by the mixed-methods methodology, is a clearer picture of the reasons why patients with chronic pain require a more multifaceted and longitudinal approach to care than an ED can deliver.The complex nature of chronic pain, in association with the high incidence of mental health issues and comorbid medical conditions seen in this group, makes the fast-paced assessment and treatment models used in the ED suboptimal for their management. Understanding the factors that bring chronic pain patients to the ED may lead to a better use of healthcare resources and improve treatment outcomes. Based on our study, we believe that interventions should target adaptive coping strategies and address the high levels of depression, anxiety, insomnia, and PTSD seen in this group. Patients who present to the ED with chronic pain have multiple mental and physical challenges that, in some cases, have not been adequately addressed by their primary care providers. We are currently testing whether access to a multidisciplinary team linked to primary care can improve clinical outcomes and reduce ED visits in this population.


Bladder cancer (BC) is one of the most common cancers worldwide. BC diagnosis and surveillance is based on cystoscopy (CS). CS impact on patient’s depression, anxiety, and sexual satisfaction (SS) is not sufficiently studied. There are no data on patient’s comfort with flexible or rigid CS.We prospectively evaluated pain perception (PP), depression, anxiety, and SS of 100 male patients who previously underwent at least one rigid CS in our department as surveillance after TURB procedure due to non-muscle-invasive BC and were scheduled for the next CS examination. The patients were randomized for flexible or rigid CS. Before CS, patients described their recalled rigid CS-related pain by NRS and fulfilled HADS and SS questionnaires. After CS, PP was re-evaluated immediately and HADS and SS within 7–10 days following the CS.p < 0.001). Mean SS score was two points lowered after rigid CS (p < 0.001). One point decrease in anxiety level was observed after flexible CS (p < 0.001). Multivariate analysis supported the hypothesis of patients benefiting from flexible CS in terms of pain perception, anxiety symptoms, and SS.The baseline scores include 5.2 ± 2.6 points for rigid CS recalled pain, 7.2 ± 3.0 points for HADS anxiety, 5.8 ± 3.5 for depression, and 27.8 ± 5.1 for SS. The flexible CS-related pain was approximately three times lower than the recalled pain level and also than the current rigid CS related (Our study demonstrates the superiority of flexible CS in terms of pain alleviation, and shifts in SS and anxiety levels. Bladder cancer (BC) is one of the most common and lethal cancers worldwide , 2. BC dCS is a procedure, which allows visualization of the urethra and the bladder walls. There are two main types of CS: rigid and flexible. Traditionally, CS is performed by means of a rigid, hollow, steel tube (cystoscope) equipped with a lens, that is introduced through the urethra into the bladder. Flexible CS, similarly to gastroscopy or colonoscopy, is based on flexible composite cystoscopes which have actively deflecting tip. Elastic body of flexible cystoscope adapts to a certain extent to the contour of the lower urinary tract and, therefore, is less traumatic. Both flexible and rigid tools were demonstrated to have equal efficacy , 4. RigiDespite the evident CS benefits, it has been shown that CS is an invasive procedure that is perceived as burdensome and is associated with pain and discomfort –8. BecauIt is crucial to concern quality of life in patients with BC, as BC is a disease which always requires long, staged, repeated and mutilating treatment with a life time period of cancer monitoring . The conOnly a few studies analysing patient ailments during and after CS are available. However, they are based on heterogeneous groups of patients and/or disorders and they are mainly retrospective or cross-sectional studies –12. MostThere are not enough objective data regarding CS impact on patient’s depression, anxiety, and sexual satisfaction. There are also no data to demonstrate authoritatively superiority of either flexible or rigid CS. We neither know how the psychological features affect pain perception during CS , 18.In this study, we prospectively evaluated pain perception and shift in depression, anxiety, and sexual satisfaction (SS) levels in men undergoing cyclic CS assessment with rigid and flexible instruments after transurethral resection of non-muscle-invasive bladder tumour (TURB).An institutional ethics committee approved the study, and all patients gave written informed consent.We prospectively evaluated pain perception, depression, anxiety, and sexual satisfaction of male patients who underwent at least one rigid CS at the Urology and Urologic Oncology Department of Wroclaw Medical University as regular surveillance after TURB procedure due to NMIBC and who were scheduled for the next CS procedure. Exclusion criteria involved patients under 18 years, with indwelling catheters, with history of any but TURB surgery on genitourinary tract, CS with intervention, symptomatic urinary tract infection, and inability to cooperate with psychological evaluations. Patients taking medications that could affect their mental states were also disqualified.All male patients that were scheduled for cystoscopy in our department and who meet inclusion criteria were invited to the study. Twenty three patients were not able to fill the initial questionnaires, and they were not included in the randomization process. Those, who did not provide SS responses, but filled HADS and PP questionnaires, were included in the study. The patients were randomly appointed to undergo flexible CS (group F) or rigid CS (group R). We used a statistical package to generate a random group assignment for the prospective enrolment. The study was single-blinded; patients did not know which procedure will be performed at the time they completed the first set of questionnaires. Seventeen patients did not resend the second set of the questionnaires and were excluded from the study. The study enrolment was stopped after both the study groups reached the expected size of 50 participants .All procedures were performed at the Urology and Urologic Oncology Department of Wrocław Medical University. One urologist (WK) conducted all flexible procedures and the majority of rigid CSs. All CSs were performed in the dorsal lithotomy position. All CSs started with routine disinfection of external genitalia and perineum with antiseptics agent. Instillation of a lubricating gel containing 2% lidocaine was performed at least 5 min before endoscope insertion. All CSs were carried out without any systemic sedation or analgesia. All endoscopes were introduced and advanced under direct operator vision. Rigid Storz 20 Fr and flexible 15 Fr ACMI cystourethroscope were used. Patients had the opportunity to observe CS on the screen. No antimicrobial prophylaxis was used routinely.Based on the preliminary assessment of the NMIBC patients (data not shown), 100 patients were calculated to be sufficient to observe at least 25% decrease in pain level after flexible CS, assuming alpha 0.05 and power of 0.80.χ2. The correlations were assessed with Spearman or gamma correlation. The rs values of 0.20–0.39 were considered weak, 0.40–0.59 moderate, and >0.60 strong associations. γ of 0.25–0.49 was considered a weak, 0.50–0.74 a moderate, and >0.75 a strong relationship.The numerical results are presented as mean ± standard deviation. Group comparison was analysed with Mann–Whitney test. The paired observations, pre- and post-CSs, were compared using Wilcoxon signed-rank test. The variations of frequencies were tested using p values are shown in the paper. The value of adjusted p < 0.05 was considered statistically significant.The Bonferroni correction for multiple testing was applied when appropriate, and the adjusted General regression model of ANCOVA was used for multivariate analysis. The type of cystoscope used during the study procedure was modelled as 1 for rigid and 0 for flexible one.All calculations were performed with Statistica v.12 .Patient’s pain perception was assessed with numeric rating scale (NRS) . An 11-pThe questionnaires were completed before CS in a room that provided privacy. After CS, patients were discharged with an addressed and stamped envelope containing the second copy of questionnaires, which was to be completed 7–10 days following the CS and resent to our department. Patients who did not complete Hospital Anxiety and Depression Scale (HADS) questionnaires or completed HADS/SS questionnaires partially were excluded from the analyses. Patients who did not resend copies of surveys were also disqualified.Anxiety and depression were measured with the validated ‘Hospital Anxiety and Depression Scale’ (HADS) . The HADThe HADS consists of two subscales with seven items scored 0–3 each, rating anxiety (HADS-A) and depression (HADS-D), respectively. Based on individual sums of scores, patients can be assigned to one of the three categories: non-case/normal (0–7), borderline case (8–10), and definite case 11–21) for both depression and anxiety. Due to high sensitivity and specificity in detecting the generalized anxiety and depression symptoms, HADS is one of the most frequently used screening tools in medical conditions  for both. HADS isSexual satisfaction was measured with The Sexual Satisfaction Questionnaire designed by Nomejko and Dolińska-Zygmunt. This tool was designed for adults at all ages and it allows to measure a patient’s attitude  towards their own sexual activity . The Sexr-Pearson coefficient of SS and global quality of life correlation was: r  = 0.453; p < 0.001. In addition, the SS questionnaire presented good internal consistency with Cronbach’s coefficient alpha at 0.83 [It was shown by that SS level measured by SS questionnaire is positively correlated with the quality of life. The  at 0.83 .The study involved 100 male NMIBC patients who were scheduled for the consecutive cystoscopy as a regular surveillance after TURB procedure. The patients who fulfilled the study criteria were randomly assigned into rigid or flexible CS group differing in CS procedure applied. The groups were proved to be age and baseline scores matched Table .rs = 0.33, p = 0.008) and weak negative correlation with sexual satisfaction  were observed. The level of the recalled pain was not related to the patients’ age, and did not associate with the anxiety level . The pain perception was slightly influenced by a result of the current CS. The positive CS, i.e., with visualization of tumour recurrence or suspicion of tumour recurrence, was described as 6.5 ± 2.3, range 3 ÷ 10, and negative as 4.6 ± 2.5, range 0 ÷ 9 (p = 0.039).The mean pain level experienced during the current rigid CS was 5.2 ± 2.6 points, with full 0 ÷ 10 range of responses Table . The levp < 0.001, Table p < 0.001). Despite overall lowering of the responses, the recalled and post-CS provided that responses remained weakly correlated with γ = 0.31 (p = 0.032). The result of flexible CS did not influence the pain perception level. The drop in pain perception observed during flexible CS was not related to any of the assessed scores nor patients’ age (data not shown).In case of flexible CS, the currently experienced pain level was much lower than the recalled rigid CS level with the mean score of 1.7 ± 1.2, range 0 ÷ 5 , but also by the recalled pain level reflecting the patients’ pain susceptibility  and slightly by the current anxiety HADS level . Patients’ age, depression symptoms, and the CS result were not independently influencing the pain level.Analysis of covariance showed that pain perception during CS is mostly influenced by the type of the cystoscope  and depression but not anxiety was shown to be age related .The HADS score results were associated and influenced by patients’ age Table . There wβ = 0.51, p < 0.001). Patients’ age and the recalled pain did not appear to have an impact on the anxiety score.In multivariate analysis, depression symptoms were the only one to associate with the initial HADS anxiety level , but also some negative impact of the rigid CS  and baseline depression  could be observed.When corrected for covariance, post-CS anxiety was mostly defined by the baseline anxiety level  with slight impact of the initial anxiety .Post-CS depression was described very similarly to the first assessment (The experienced pain level and patients’ age did not have a direct effect on the anxiety nor depression level post-CS.p < 0.001) but did not differ in terms of anxiety, depression, or pain perception from other study participants.The mean SS score reported initially by the study participants was 27.8 ± 5.1. There was a group of patients, who did not fill the SS questionnaire. They were older . There was a weak negative association of sexual satisfaction with patients’ age .Both anxiety and depression negatively correlated with sexual satisfaction score , depression symptoms , and recalled pain perception .Multivariate analysis, including age, HADS, and PP scores, showed that baseline SS score was negatively influenced by the baseline anxiety , but was not observed in group R.SS after the current CS was not associated with pain perception Table . In addiβ = 0.90, p < 0.001), but also a negative impact of the rigid CS  could be observed in the multivariate analysis.Sexual satisfaction scores provided that post-CSs were strongly associated with the previously described baseline SS level  often reaching ten points, which is quoted as “unbearable pain” [During the current CS, it was demonstrated that pain associated with flexible CS was three times lower (mean 1.7 ± 1.2) than reported after rigid CS (mean 5.2) independently of patients’ age. In addition, no one patient after flexible CS rated pain perception for more than five points, whereas after rigid CS, eight patients rated pain as severe (8–10 points).The recalled and current pain perception scores are correlated, even in the case of observed pain decrease after flexible CS. It suggests that patients have a given susceptibility to pain perception, regardless of a performing physician and the cystoscope type.A rigid CS with a positive result, i.e., visualization of tumour recurrence or suspicion of tumour recurrence, was more painful than the negative one. Positive rigid CS may be more painful due to the fact that suspicious areas are always meticulously visualized, thereby increasing the amount of cystoscope manipulation and often CS time. There was no difference in pain perception caused by the flexible CS result, which also supports the superiority of the flexible cystoscope.In addition, mental syndromes may interfere with invasive examinations resulting in greater pain perception . We obseIn many patients, the anticipation of pain caused by CS can be a sufficient motive not to undertake primary diagnosis or waive the cyclic surveillance after TURB. This relationship is likely to be particularly pronounced in patients with psychological disorders –33. For It has been proved that oncological patients have increased anxiety and depression levels compared to general population . It has There are no available data on anxiety and depression levels measured by HADS scale in general Polish population. In somehow similar German population, the mean scores for anxiety and depression in males are 4.4 and 4.8. Using the cutoff 8+, the percentages of elevated anxiety and depression in the total sample are 21 and 23%, respectively . In the In Polish population of testicular cancer, average severity of anxiety was 5.71. The prevalence of anxiety disorder (8–10 pt.) was 40% and anxiety syndrome (11+ pt.) −15% in patients during chemotherapy [We observed that the level of anxiety reported after a few days post-CS is positively influenced by flexible CS. This observation could be explained by the fact that less pain during CS not only allows to quickly reduce psychological tension after procedure, but also gives insights that the future surveillance can be less burdensome. What was similar with Seklehner et al. conclusions, depression levels did not change after CS notwithstanding the used method . FurtherSome authors state that HADS levels are “falsely” elevated before CS, as CS contributes considerable stress to the examinee. We have not observed any decrease in anxiety following rigid CS examination. However, when a less painful flexible CS was performed, the patients’ anxiety was reduced.It is in agreement with Seklehner et al., who demonstrated that in patients who anticipated rigid CS anxiety levels were higher comparing to flexible CS .In our paper, we showed that sexual satisfaction is negatively influenced by the anxiety and depression symptoms. We could also observe the negative impact of pain susceptibility on SS score. Although we were not able to prove an independent influence of age on sexual satisfaction, we noted that patients who were not responding to SS questionnaire were older.Sexual satisfaction scores provided that post-CSs were strongly associated with the previously described baseline SS level; however, a negative impact of the rigid CS on SS was observed. We observed that there was no change in SS levels after CS in patients undergoing flexible procedure. In rigid group, although there were no large differences in the general analysis, the paired evaluation of pre- and post-CS results showed a significant decrease in SS after rigid CS and demonstrated negative association with anxiety. Once more, post-CS SS was negatively related to depression. It clearly shows that rigid cystoscopy has a negative impact on patients’ sexual well-being.It is widely known that satisfaction with sexual life is of great importance in the global assessment of quality of life made by adults , 44. It It was reported that rigid CS might transiently impair functional sexual performance and libido in ¾ sexually active patients , 29. HowOur study has some limitations. The rigid cystoscopies were not performed by the same urologist. CS, such as every surgical procedure, may be performed slightly differently among urologists. As the patient’s discomfort may (to some extent) depend on the way, the CS is performed, and it could have some effect on the results. Second, study was conducted in one university centre and on a relatively small sample. However, the group was very homogenous. There might have been some qualification bias, as we included only patients that were able to fill out surveys without the help of the third parties. We also lost some of the participants for two reasons. Twenty three patients were unable to fill the initial questionnaires, which might have resulted from strong anxiety at the admission for CS. In addition, 17 of the enrolled patients did not send the second copy of the questionnaires. It is possible that depressive patients were less willing to fill out the second copy of surveys, and, therefore, were not included in the analysis. Finally, there might have been some qualification bias, as we included only patients that were able to fill out surveys without the help of third parties. Possibly, the paper does not include a complete cross section of NMIBC patients. It is likely that the paper presents younger and also more sexually active group.Our study provides the general characteristics of anxiety, depression symptoms, and sexual satisfaction of NMIBC patients. We show the superiority of flexible CS over the rigid one in terms of pain perception, but also in sexual satisfaction or anxiety levels in male patients who were under cyclic surveillance after TURB because of NMIBC. Modern flexible video cystoscopes are characterized by excellent image quality, and wide range of active tip deflection, which allows for visualization of whole bladder mucosa, especially the sites which are difficult to access using rigid CS. The improvement in patients’ comfort together with excellent diagnostic results obtained with modern flexible cystoscopes make them a method of choice for bladder examination in male patients.


Several studies have compared instrumented PLF with other surgical approaches in terms of clinical outcomes, however little is known about the postoperative HRQoL of patients, especially as regards to degenerative spondylolisthesis.via the visual analogue scale (VAS) for low back pain (VASBP) and leg pain (VASLP) separately. Their HRQoL was evaluated by the Short Form (36) Health Survey (SF-36). Both scales, VAS and SF36, were measured and re-assessed at 10 days, 1 month, 3 months, 6 months, 12 months and 2 years.A group of 62 patients, 30 women  and 32 men  with mean age 56,73  years old, were selected to participate in a 2-year follow-up. Their pain was assessed VASBP, VASLP and each parameter of SF36 presented statistically significant improvement (p<0.01). VASBP, VASLP and SF36 scores did not differ significantly between men and women (p≥0.05). The most notable amelioration of VASBP, VASLP was observed within the first 10 days and the maximum improvement within the first 3 months. From that point, a stabilization of the parameters was observed. The majority of SF36 parameters, and especially PF  and BP (bodily pain), presented statistically significant improvement within the follow up depicting a very similar improvement pattern to that of VAS.We conclude that instrumented PLF ameliorates impressively the HRQoL of patients with degenerative spondylolisthesis after 2 years of follow-up, with pain recession being the most crucial factor responsible for this improvement. While the conservative treatment of degenerative spondylolisthesis has remained unchanged, the number of surgical techniques has increased over the last two decades .Posterolateral instrumented fusion (PLF) referring to the combination of lumbar laminectomy for decompression and transpedicular instrumentation using pedicle screws and rods for stability, is one of the two main approaches to spinal fusion; the other is interbody fusion (IBF). Several studies have compared these two surgical approaches in order to evaluate the efficacy of each one of them in terms of pain relief and clinical outcomes . HoweverOur primary hypothesis was that the postoperative low back pain, the radiating leg pain and also, the various aspects of the quality of life of patients with degenerative spondylolisthesis and spinal stenosis would be significantly improved after posterolateral instrumented fusion surgery.22.11). The patients were recommended for surgical procedure after failing non-operative treatment.From January of 2012 to January of 2015, 80 patients were subjected to PLF and 62 of them were selected to participate in a prospective clinical study in order to evaluate the effectiveness of this specific surgical technique as regards to pain levels and quality of life. The surgical procedure included neural decompression by laminectomy and foraminotomy, spinal stabilization by posterolateral fusion, pedicular screw and rod instrumentation and the fusion was performed by applying a mixture of an autogenous bone graft and an allograft Fig. (2). Spondylolisthesis grading was recorded according to Meyerding’s scale [The diagnosis of spinal stenosis was established by MRI. Preoperative plain radiographs of the lumbosacral spine were obtained for all patients. Radiographs were evaluated before surgery for the type of spondylolisthesis and severity of slip for each patient Fig. :Intermittent neurogenic claudicationDeteriorating chronic low back pain + radiating leg pain (radiculopathy)Spondylolisthesis level I or II, in plain profile x raysSpondylosis' findings in MRI images in compliance with the clinical findingsCompliance with one of the types of Adult Spinal Deformity (ASD) classification system Fail of conservative treatment (medication + physiotherapy)2.2Radiating leg pain as a single symptomBone fractureDisc hernia as a single MRI findingRecent lumbar spine traumaSpine tumor or infectionIsthmic spondylolisthesis (spondylolysis findings in CT and MRI images)Severe slippage (advanced third- fourth degree listhesis)Reoperation.3via the visual analogue scale , for low back pain and leg pain separately [62 patients were selected to participate in a 2-year follow-up. Their pain was assessed parately . Their h3.1The SF-36 scoring scale has 36 items. The item 2 is self-reported health changes and does not participate in scoring. The remaining 35 entries constitute 8 dimensions, physiological function , physical function , bodily pain , general health , energy , social function , emotional function  and mental health . The higher the total score of all these 8 dimensions, the better the quality of life. If respondents answered less than half of the number of entries then their questionnaires were considered invalid. SF-36 has shown good reliability, consolidation validity, discrimination validity and criterion-related validity [3.2The statistical analysis of this study was performed with the statistical package SPSS, version 16.00 . The p-value <0.05 was determined as statistically significant difference level. We used Wilcoxon test to compare the group values pre- and postoperatively, and the Mann-Whitney U-test to compare values between men and women.4After all inclusion and exclusion criteria were considered, we finally analyzed the results of 62 patients who underwent instrumented PLF, in an attempt to evaluate their low back pain (VASBP) and leg pain (VASLP) after surgery, as well as, their postoperative quality of life by measuring the parameters of the SF36 scoring scale as described above. All patients underwent the procedure successfully. There were no intra-operative complications. All selected patients successfully reached the end of the follow up. Thus, the percent of the 2-year follow up is 100%. From the patients included, 30  were women and 32  men. The mean age was 56,73  years old. Concerning the postoperative complications, there were two cases of postoperative superficial wound infection and one case of temporary postoperative radicular pain. Out of 62 patients, 60 had good bony fusion demonstrated on postoperative X-ray A-P view. Only 3 had pseudoarthrosis at 6 monthly follow-up X-ray. The VASBP, VASLP and SF36 scores did not differ significantly between men and women (p≥0.05).3, 4). During the second postoperative trimester we can see a slight improvement too. From that point to the end of our follow up limit (2 y), there is a stabilization of both our parameters. Physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional are the most improved parameters within the 2 years follow up, with the best results being observed within the first trimester and then being stabilized . As regards to the improvement of values, a similar pattern is observed between the VAS and the SF36 postoperative scores .In total, VASBP, VASLP and each parameter of SF36 present statistically significant improvement (p<0.01). We can observe that the most notable amelioration of VASBP and VASLP respectively takes place within the first 10 days postoperatively, while the maximum result is observed almost within the first 3 months Figs.  is a well-established and a time-tested surgical procedure for the treatment of lumbar spondylolisthesis. It has been stated that decompression mainly relieves radicular symptoms and neurogenic claudication, while fusion primarily relieves back pain by stabilizing the spine. Also, the addition of instrumentation leads to a solid arthrodesis . SpecifiBased on our results, it was proven that lumbar decompression with laminectomy, combined with PLF provides very satisfactory clinical outcomes after 2 years of follow up. Great improvement was observed in VASBP and VASLP scores within 3 months postoperatively with leg pain almost disappearing in a 2-year time. From 3 months to 2 years the results remained almost stable (with a slow amelioration) and very satisfactory. The SF36 measured parameters related with the quality of life confirm the amelioration, especially the PF and BP improvement which reaches a very satisfactory result in 10 days time and stabilizes after the first year. Additionally, the other parameters of the SF36 show very satisfactory results within 10 days follow up as well. The results mentioned above indicate that pain and quality of life parameters are depended, so that the low back pain recession and the leg pain almost total extinction help patients to fulfill in some cases seamlessly not only their physical activities but different aspects of their life.et al. and Liu et al. comparative studies, showed moderate-quality evidence of PLIF procedures’ advantage in pain and satisfaction compared to PLF [et al. compared the radiological and clinical outcomes (VAS and ODI scores) of patients suffering from isthmic and degenerative spondylolisthesis and the results revealed that decompression and PLF improve significantly both pain and disability in both groups of patients [Various studies in the relevant literature have tested the efficacy PLF in comparison with PLIF as regards to lumbar spondylolisthesis. Luo d to PLF , 9. Howed to PLF . Taking d to PLF . Concernpatients . Neverthet al., when a multi-level fusion is considered, the proximal fusion levels should be carefully determined [Sometimes it is difficult to decide which is the appropriate surgical procedure in order to avoid certain pitfalls. PLIF has been proposed for high grade spondylolisthesis, which requires reduction or if the disc space is still high. When the slip grade is low, or the disc space is narrow, the PLF should be preferred . For lowtermined .et al. conclude that TLIF and instrumented PLF are equally efficacious options in the treatment of Grade I and II spondylolisthesis, except lytic type [Newer techniques have emerged and the need for more comparative studies is obvious. It is considered that TLIF may be performed easily, safely and effectively with fewer complications for patients with lumbar spondylolisthesis . Ghasemitic type .et al. compared a group of patients suffering from degenerative spondylolisthesis who underwent PLF with those treated with ALIF and found that the last group had a better VASBP improvement after 2 years follow up  [Ohtori ctively) . PLF trectively) .Minimally invasive spine surgery has recently gained a position in spinal fusion as well. Facet fusion has shown good clinical outcomes that might be superior to those of conventional PLF with a comparable fusion rate. Miyashita mentions that it is useful for managing degenerative lumbar spondylolisthesis and is a minimally invasive evolution of PLF . The MISet al. compared circumferential fusion vs PLF in patients with spondylolisthesis and did not show significant difference between the two methods in clinical satisfaction. PLF can reduce complication rate and shortens operating time and CF has an advantage of restoring lumbar alignment and improving fusion rate in patients with isthmic spondylolisthesis [et al. reported that substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or disc degeneration disease exists [et al. concluded that PLF is an efficient technique for the surgical treatment of degenerative spondylolisthesis. However, TLIF did not show its superiority neither in clinical nor alignment parameters despite a better fusion rate. As a result, it was suggested that TLIF is not mandatory in this specific indication [Several metanalyses have studied the efficacy of PLF in comparison with other procedure. Liu isthesis . It has isthesis , 2. Carre exists . Recentldication .The present study has several limitations. Due to the design, there was no proper control group because the objective of this study was not to emphasize on the comparison between PLF and other procedures, but to present the early results on the improvement of the quality of life of patients and the recession of pain. We did not want to include the widely used Oswestry Low Back Pain Questionnaire (ODI) or other questionnaires because we believe that SF-36 is a multi-scaled questionnaire which is more complete tool for quality of life including emotional and mental sections. In our opinion, SF36 in combination with VASBP and VASLP as research tools, are the most appropriate for this specific study and its purpose. Furthermore, it would increase the significance of our study results if we considered designing a follow-up lasting more than 2 years.New studies focus on the results and advantages of MIS techniques, given that they reduce post-surgical pain, shorten hospitalization and minimize surgical time and complication rate. Despite the new trends in spine surgical therapies, open methods as PLF still remain the gold standard therapy in central spinal stenosis, due to the MIS methods limitations and their application on selective patients.Finally, we can conclude that, despite the advantages of PLIF procedures in spinal alignment and restoration, when we study patients suffering from degenerative lumbar spondylolisthesis, decompression of lumbar spine and PLF offers significant and remaining relief from the symptoms, while on the same time clearly upgrades the patients’ quality of life, so that it can be considered the surgical procedure of choice for this group of patients.


Chronic low back pain is a common, disabling and costly health problem. The treatment of chronic low back is difficult and is often ineffective. For treatment to be effective the cause of the pain has to be established but unfortunately in 80% to 95% of the patients the cause cannot be determined despite the existence of modern imaging techniques. A pathoanatomical diagnosis which fits into a classical disease model where successful treatment can be carried out, can only be made in 5% to 7% of the patients. The back pain in the rest of the patients where no pathoanatomical diagnosis can be made is often labelled, unscientifically, as chronic low back pain. Despite the existence of sophisticated imaging techniques and a plethora of diagnostic test the source of pain in patients with nonspecific back pain cannot be established. There exist no causal relationship between imaging findings of degenerated disc, lumbar facet arthritis, spondylosis, spondylolysis and spondylolisthesis, to the pain in these patients. Surgical treatment of non-specific back pain where no pathoanatomical diagnosis has been established is bound to fail. Therefore the outcome of spinal fusion in these patients can be no better than nonsurgical treatment. Spinal fusion is a major surgery which can be associated with significant morbidity and occasionally with mortality. Yet there is rapid rise in the rates of spinal fusion. There is a growing tension between ethics and conflicts of interest for surgeons. The spine, unfortunately, has been labelled as a profit centre and there are allegations of conflicts of interest in the relationship of doctors with the multi-billion dollar spinal devices industry. The devices industry has a significant influence on not only research publications in peer review journals but also on decisions made by doctors which can have a detrimental effect on the welfare of the patient. Low back pain represents a common disabling and costly health problem. Unfortunately the cause of back pain can be accurately diagnosed and treated in only a small proportion of the patients, where specific spinal pathology such as tumours, infection, fractures and nerve root pain caused by prolapsed disc or spinal stenosis, is present. In vast majority of the patients the cause of the pain is not known and such pain has been unscientifically labelled as non-specific back pain. A pathoanatomical diagnosis cannot be made in these patients, even with modern diagnostic imaging techniques such as magnetic resonance imaging of the spine, and this makes the treatment of non-specific back pain difficult. Surgeons are treating the symptom back pain and not a disease, with surgery, when they offer spinal fusion as a modality of treatment to such patients. This is partly due to an ‘orthopaedic surgery lacuna’ which is caused by the nature of training received by orthopaedic or spinal surgeons. Surgeons are trained to treat conditions which are amenable to surgery and are not trained to treat patients who do not need surgery unlike the neurologists and cardiologists who are trained to treat patients who do not need surgery. This ‘surgical lacuna’ has led many surgeons to believe that spinal fusion surgery will cure the patient of chronic low back pain and this is partly responsible for an exponential increase in rates of spinal fusion around the world. Besides this, there is a strong element of conflicts of interest which has caused a spike in spinal fusion rates. When surgery is done for a symptom and not for a disease the outcome tends to be poor and this increases the risk of negligence suits. It is common knowledge that litigations in this arena in Malaysia is on the rise. Is there justification for spinal fusion in the treatment of patients with non-specific low back pain?1.A review of the literature reveals that there is no uniform definition for chronic or recurrent low back pain although a uniform definition is essential for the study of prevalence and treatment outcome of low back pain. There appears to be some consensus that low back pain which persists for at least 12 weeks can be classified as chronic low back pain and that which is present for less than 6 weeks can be classified as acute back pain. Back pain that last between 6 weeks to 12 weeks is often classified as subacute back pain. Repeated episodes of back pain cannot be classified as chronic back pain although such bouts of back pain have been present for many years unless each episode of back pain last for at least 12 weeks. An episode of back pain is defined as back pain lasting for at least 12 hours and recurrent back pain would be defined as the presence of least two such episodes in a yearSpecific spinal pathology which can be found in 1% to 2% of patients. This would include diagnoses such as tumours, infections, fractures and cauda equina syndrome.Radiculopathy caused by disc prolapse and spinal stenosis which is seen in about 5% of the patients.2.Non-specific low back pain which occurs in about 85 to 95% of the patientsWaddell’s classification of low back pain is widely accepted though there are several available classification for low back pain. Waddell’s diagnostic triage divides low back pain into three categories;2. The belief that diagnoses such lumbar strain or degenerative spine disease causes chronic low back pain remain unfounded and this leaves a lot of room for uncertainty about treatment, prognosis and clinical outcome2.In this diagnostic triad, the first two categories encompass a proper pathoanatomical diagnosis which fits into a classical disease model and this makes effective treatment possible. On the other hand with the third category, the absence of a pathoanatomical diagnosis makes effective treatment fraught with difficulties. Waddell has eloquently described a diagnosis of non-specific backache as ‘intellectually and scientifically inadequate and it fails to provide any biological basis for real understanding’ which results in treatment remaining ‘empirical or based on unproven hypotheses’Spinal fusion, for progressive or unstable spondylolisthesis, spinal trauma, tumours and spinal infections, has a well-established role and the outcome is good because there is a pathoanatomical diagnosis. On the other hand in patients with non-specific back pain where no pathoanatomical diagnosis exit and the cause of back pain is not known the value of spinal fusion remains questionable. Eliciting the cause of back pain in patients with chronic non-specific back pain remains a dilemma.3. The disc is implicated in about 40% of the patients with non-specific low back pain4. The facet joints is believed to be the source of low back pain in 15 to 40% of the patients5 while the sacroiliac joint is implicated in about 15% of the patients6. Though we believe that these three are the main sources but not the only source of chronic low back pain, no conventional clinical test can discriminate the source of pain in patients with disc, facet joint or sacroiliac joint abnormalities6.The degenerated intervertebral disc is most often implicated as the cause of pain in patients with non-specific low back pain. Such pain is usually referred to as discogenic back pain. Disc degeneration leading to abnormal shock loading of the disc and micro trauma to annulus and the endplate is believed to cause the pain. This trauma to the annulus and the endplate also allows blood vessel and nerve ingrowth into the normally avascular and aneural disc7. Systematic review of published studies show that there is a lack of firm evidence for a causal relationship, between radiographic findings of degeneration of the spine as defined by disc space narrowing, osteophytes and sclerosis, and non-specific back pain. Neither does a causal relationship exist between radiographic evidence of spondylosis, spondylolysis, spondylolisthesis, spina bifida, transitional vertebra nor with Scheuermann’s disease and non-specific back pain8.A simple relationship of radiographic structural abnormalities of the lumbar spine and low back pain cannot exist because many individuals with such structural spinal abnormalities are asymptomatic9. In asymptomatic adults, degeneration of the disc can be seen in about 40 to 80% of individuals and it increases with age, disc protrusion can be seen 40 to 70%, end plate changes in 10 to 30% and annular disruption in 25 to 70% of adults who are asymptomatic10. Jansen et al11 in a study of 98 asymptomatic individuals found that an MRI examination of the spine revealed a normal disc in only 36% of the individuals. Fifty two percent had a disc bulge at one level, 27% had disc protrusion and 1% had disc extrusion. 19% had Schmorl’s nodes, 14 % had annular tears and facet arthropathy was present in 8% of the subjects. The findings were the same in males and females. The high prevalence of these findings in asymptomatic individuals and a high prevalence of back pain in general population suggest that the MRI findings of bulges or protrusions in people with low back pain may frequently be coincidental. Hence it makes sense that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms present before surgery is contemplated.Modern imaging techniques can now allow us to accurately depict the anatomical changes that occur with the degeneration of the disc. However, the clinical significance of these changes depicted on magnetic resonance imaging (MRI) remains elusive and often confusingSince anatomical diagnostic tests such as radiographs and magnetic resonance imaging the gold standard are of not much help in elucidating the cause of non-specific low back pain, can other tests help in making a decision as to which of the patients with non-specific low back pain will benefit from surgery? Discography has in the past been advocated by some proponents as a useful decision making tool.12. It is important to know whether discography can accurately define the disc that is generating the patient’s pain for it to be any use in spinal surgery.Discography is used to determine if the low back pain the patient is experiencing is caused by disc pathology. In this procedure dye is injected at pressure of between 15-25 psi, under fluoroscopy, into the suspected disc while the patient is sedated. If the injection reproduces the pain at the same site that the patient has been experiencing before the procedure then it is believed that the disc is the source of the patient’s low back pain (positive discogram). However there is no universally accepted definition as to what a concordant pain response is and there is a lack of reliability studies on discographyWe know that imaging of the spine with scans can reveal the degenerated morphology of the disc but the scans cannot tell us that the disc is the source of the pain. This is obvious from the fact that the imaging morphology of the disc does not change over short periods of time but the patient’s symptoms do. Can a discogram which is an invasive procedure with potentially serious complications such as discitis, provide us with the information needed regarding the source of the patient’s pain?13 (2002) have proposed that a critical test of validity of a diagnostic procedure involves measuring it against a gold standard in a clinical setting. The test should be able to distinguish between patients with and those without the target disorder or low back pain and furthermore patients who undergo the test should fare better compared to those patients who did not have the test. Unfortunately there is no reasonable gold standard against which to test discography. Despite the lack of proven validity against a gold standard, discography has been used to recommend spinal fusion in patients with non-specific low back pain.Sackett and Hayeset al14 (2006) did a study to test the hypothesis that positive provocative discography will accurately identify patients with low back pain due to a primary discogenic lesion and a clinical cure will be achieved in such patients with a successful spinal fusion. This prospective study was carried out between 1996 and 2000. The first cohort of 32 patients had an episode of low back pain for 6 to 12 months which did not respond to conservative treatment and the discogram was positive at one level with a normal discogram at adjoining levels. The second cohort included 34 patients with an unstable spondylolisthesis who did not respond to conservative treatment. Patients with selection comorbidities such as compensation claim, abnormal psychometric test, occupational disabilities and prior lumbar surgery were excluded. The patients were followed up for 2 years.Carragee14. The study showed that provocative discography is not highly predictive in identifying intradiscal lesions as a cause of chronic low back pain. The usefulness of the test hence remains to be proven.When a high level criterion of successful outcome (highly effective) was adopted, 71.9% of patients in the spondylolisthesis group had a successful outcome after spinal fusion and in the discogenic group only 26.6% had a successful outcome. When a low level criterion of successful outcome  was used 91.7% of the spondylolisthesis group had a successful outcome as compared to 43% in the discogenic group. After ‘adjusting for surgical morbidity and drop out failure, by either criteria of success, the best case positive predictive value of discography was calculated to be 50% to 60%’et al15 (1999) did an experimental disc injection in patients who had no past history of low back pain but developed back or buttock pain after posterior iliac graft harvesting for non-thoracolumbar surgical procedures. They studied 8 subjects who had 24 disc injections and 14 disc injections produced some pain response, 35.7% produced non-concordant pain, 50% produced similar pain and 14.3% of the injections produced the ‘exact’ pain. By the usual criteria for positive discography, 50% would have been classified as positive in this group of patients who had no back pain prior to the graft harvest. The response of concordant pain on discography appears to be less meaningful than is often believed.False positive findings on discography are also common. Carragee 16. Can spinal fusion be an effective procedure for treatment of chronic non-specific low back pain when there are no accurate diagnostic tests to identify patients who will benefit from such treatment?Systematic review of accuracy of other tests such as orthosis immobilization and temporary external fixation of the spine to identify patients with chronic low back pain for whom spinal fusion is a predictable and effective treatment has not proved to be useful17. In England there has been an almost direct relationship between the numbers of operations performed per year and number of orthopaedic and neurosurgeons per head of population18. Do the results of spinal fusion justify the increase in fusion rates or are there some conflicts of interest?None of the imaging studies or other diagnostic test is able to accurately localise the source of pain in patients with non-specific low back pain. How can we then expect lumbar fusion to effectively treat the patient’s pain? Yet there has been a rapid increase in fusion rates (336%) of the lumbar spine from 1996 to 2001in the United States of Americaet al19, in 2005, published the results of a randomised controlled trial which assessed the clinical effectiveness of spinal stabilization or fusion compared to intensive rehabilitation for patients with chronic low back pain. Their cohort included 349 patients between the ages of 18 to 55 years with at least one year of low back pain who were considered by an experienced surgeon that they were candidates for spinal fusion. The patients were randomised into two groups, 176 to the surgical group and 173 to the rehabilitation group. The cohort was followed up for 2 years. At 2 years the clinical outcome was assessed using the Oswestry low back pain disability index, which is scored 0% (no disability) to 100%  and is designed to assess the limitation of activities of daily living. Other assessments included the shuttle walking test, short form (SF) general health questionnaire, and psychological distress and risk assessment (DRAM).Fairbank The mean Oswestry disability index changed favourably from 46.5 to 34 in the surgical group and from 44.8 to 36.1 in the rehabilitation group. The mean difference between the groups was about -4.1 in favour of the surgical group. There was no difference between the groups in the shuttle walking test and other outcome measures. There were surgical complications in 19 patients. Eleven patients in the surgical group had reoperations. Complications included dural tears, excessive bleeding, implant problems, fractures and vascular injury.The study showed that there was no clear evidence that primary spinal fusion surgery was any more beneficial than intensive rehabilitation in patients with chronic low back pain. Surgery while not having any superiority over conservative management was associated with potential risk and increased cost.et al20 (2010) did a 4 years follow up of patients to compare surgical versus non-surgical therapy in the treatment of chronic low back pain. In this study of two merged randomised clinical trials the authors compared instrumented transpedicular fusion with cognitive intervention and exercises in 124 patients who had disc degeneration and one year of symptoms. This study included some patients who had previous surgery for disc herniation while others had no previous spinal surgery. Of the 124 patients 66 patients were assigned to the surgical group and 58 to the non-surgical group.Brox The study showed that lumbar fusion was not superior to cognitive intervention and exercises at reliving back pain, improving function and return to work at 4 years. However there were 14 patients (24%) randomised to the non-surgical group who underwent subsequent surgery (non- adherence to protocol) while 15 patients (23%) in the surgical group had to undergo reoperation.20. It is a fallacy to believe that new technical solutions in the hands of a skilled surgeon will provide faster and greater improvements in the patient’s symptoms unless the solutions are based on sound knowledge backed by good randomised studies. At the present time there is insufficient evidence to determine the effect of fusion compared to non-surgical treatment. Methodological limitations of the published randomised trials prevent any firm conclusions to be drawn on the effectiveness of spinal fusion for chronic low back pain21.These studies lack placebo controls. The improvements in the surgical group may be placebo mediated. Hence it is not possible to know whether the marginal positive outcome in these patients reflect the natural course of the disease, placebo effect, patient expectation, or the care provided22.The Agency for Healthcare Research and Quality (ACHR), U.S. Department of Health and Human Services which conducts the effective health care program as part of its mission to organise knowledge, has conducted an extensive comparative effectiveness review of spinal fusion for treating painful lumbar degenerated discs or joints and has come to the conclusion that there is insufficient evidence to determine the benefits of lumbar fusion compared to more intensive rehabilitation programsIn the absences of sufficient evidence of benefits of spinal fusion for chronic non-specific low back pain, is it safe to recommend the procedure to patients?Spinal fusion is a major surgical procedure which involves extensive dissection, decortication of bone, blood loss and longer operating time. Often implants have to be used. More extensive and prolonged procedures are usually associated with more complications. There is a tendency among spinal surgeons to correct all anatomical abnormalities to prevent future symptoms, leading to more complex fusions, although there is no evidence that such ‘prophylactic’ surgery has any benefits. Complex fusions include multi-level surgery involving multiply approaches.et al23 (2010) did a study to evaluate major complications in Medicare patients undergoing surgery for spinal stenosis in the United States in 2007. Their study of Medicare data avoided the bias which is often associated with studies by surgeons of selected patients from select centres. They were able to obtain nearly complete data on repeat hospitalization and mortality.Deyo They studied 32,152 patients who had surgery for spinal stenosis in the first 11 months of 2007. The patients were 66 years and above. They analysed major medical complications, wound complications and the 30 day mortality. The major medical complications included those that needed cardiopulmonary resuscitation or repeat endotracheal intubation and mechanical ventilation due to cardiorespiratory arrest, acute myocardial infarct, respiratory failure, pulmonary embolism, pneumonia and stroke. The wound complications included haemorrhage, haematoma, seroma, wound break down and post-operative infections. Mortality included all deaths within 30 days of hospital discharge.In patients who had complex spinal fusion, there was a 5.6% rate of major complication and the 30 day mortality was 0.6%. Complex fusions had an odds ratio of 2.95(95%CI) for life-threatening complications compared to decompression without fusion. The re-hospitalization rate was 13% in patients who had complex fusions. The wound complications were also higher in patients who had complex procedures.et al24 (2001) comparing surgical with non-surgical treatment for low back pain 18% of the patients in the fusion group developed early (within 2 weeks) complications and 6% had late complications. Complications included, bleeding, neural injury, heart failure, major GI bleeding, pulmonary oedema, aspiration sepsis, pulmonary embolism, dural tears, haematomas, pseudoarthrosis and even wrong level surgery. In patients who had complex fusion the complication rate was 31%. The reoperation rate in the surgical group was 6%.In a study by Fritzell et al25 (2003) in a study comparing instrumented lumbar fusion with conservative treatment for chronic low back reported a 18% complication rate in the surgical group. In the Fairbank19 (2005) study the complication rate in the surgical group was 10.7% and the reoperation rate was 0.6%. In the 2010 Brox et alstudy20 the reoperation rate in the surgical group was higher at 23%.Brox 22. Nevertheless, complications associated with spinal fusion are not uncommon and can be life-threatening.There are wide variations in the complication and the reoperation rates in these studies because of insufficient reporting and variations in surgical techniques. This makes it difficult to determine conclusively the complication rates of lumbar fusion in these patientsDespite a lack of superiority of spinal fusion over non-operative treatment of patients with chronic non-specific low back pain, there has been a steep rise in the rates of spinal fusion over the last two decades. Spinal fusion is also associated with morbidity and mortality. This begs the question as to why there is such a trend.26.There is growing tension between ethics and conflicts of interest with some surgeons becoming less altruistic and allegations of unethical behaviour among doctors becoming more rampant. The American press is often inundated with reports of unethical behaviour among doctors and these include accusations of exorbitant professional charges, royalties paid to doctors without intellectual property and marketing of medical products and services by doctors for economic gain. Spinal fusion for chronic low back is one such service. Spinal fusion is one of the most lucrative areas of medicine and it generates billions of dollars for the hospitals and the surgeons27. Studies show that a higher proportion of fusion procedures and the introduction of new spinal implants between the years 1993 to 1997 did not reduce re operation rates. In fact the reoperation rates were higher in the late 1990’s as compared to the early 1990’s27. The authors were of the opinion that introduction and marketing of new surgical devices and the influence of key opinion leaders is the likely reason for invasive procedures in the absences of new indications. Other possible reasons being financial incentives to hospitals and surgeons as well as the desire of surgeons to be innovators.In the year 2001 in the United States, 122,000 lumbar fusions were carried out for degenerative disease of the spine and this represented a 220% increase from 1990. This increase became more obvious after 1996 when fusion cages for spinal fusion became available. The increase in lumbar fusion from 1996 to 2001 was 113%, while for hip and knee arthroplasty it was only 13% and 15% respectively28.The influence of key opinion leaders and financial incentives for surgeons has hit the headlines in major U.S. newspapers in recent years. Allegations of kickbacks to spine surgeons to use their products, relationship of surgeons to biomedical firms with financial arrangements involving multibillion dollar medical devices industry have been highlighted29. Subsequent non-industry studies showed that the use of rhBMP-2 was associated with many complications30.One such debacle was that of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2), a bone growth factor for spinal fusion. The Spine Journal, June issue 2011, gained attention from surgeons, researchers, patients, media, and industry when it focused attention on the controversial rhBMP-2 synthetic bone growth factor for use in spinal fusion surgery. It highlighted the limitation of industry sponsored research, bias in research development and reporting as well as weaknesses of peer review publications and inadequate disclosures and ethical shortcomings. The industry sponsored doctors involved in the promotion of rhBMP-2 through publication of studies in peer review journals which showed no complications with the use of rhBMP-2, received millions of dollars in royalties from Medtronic, the manufacturer of the product31. This has sparked fears that this would provide extra financial incentive for surgeons to recommend spinal fusion.Conflicts of interest through consulting ties and other relationship with device manufactures aside, doctors have now started becoming investors in spinal implant manufacture and distribution. As of Oct 2012, there were at least 20 states in U.S. with multiple active physician owned distributorships (PODs) which supply devices to hospital, with California alone having 40 such distributorships32. In 2011, PODs supplied devices used in one in five spinal surgeries billed to Medicare and contrary to claims by such distributorships the cost were not lower. A third of hospitals surveyed purchased devices from PODs. After hospitals started buying devices from PODs, the rates of spinal fusions grew faster in hospitals that bought devices from PODs compared to fusion rates in hospitals overall. In 2012, surgeons did more spinal surgeries at hospitals that purchased spinal devices from PODs than at hospitals that did not get their devices from PODs.This prompted the Congress in the U.S. to ask the U.S. Department of Health and Human Services to investigate the prevalence and use of spinal devices supplied by physician-owned distributorships (PODs)26. Some have gone further to described this new business model as ‘low hanging fruits’ waiting to be plucked and not to be deprived of the opportunity Malaysian surgeons have jumped on the bandwagon33.This new and growing area of partnership between surgeons and the device manufacturers has led some surgeons to express concern about such partnerships, because, they believe that it is unethical and it will bias the doctor’s choice of what is best for the patient. Others have described such partnerships as ‘an awfully pernicious conflict of interest’ for doctorsThere appears to be some consensus now regarding the definition of chronic low back pain though there are various definitions in published studies. Uniformity of definition will provide a basis for effective study of the prevalence and outcome of treatment of patients with chronic non-specific back pain.Unfortunately in patients with chronic low back pain a specific pathoanatomical diagnosis can only be made in about 5% to 7% of the patients where treatment can be effective. In about 85% to 95% of the patients with chronic low back pain a pathoanatomical diagnosis cannot be made and this makes effective treatment difficult. In such patients non-specific chronic back pain is a symptom and not a disease. Logically a symptom cannot be treated by surgery.Degenerated disc is usually implicated as the cause of chronic low back pain in most of the patients while in others the lumbar facet joints and the sacroiliac joints are believed to be the cause of chronic low back pain. Anatomical changes of degenerative pathology of the spine which are accurately depicted by MRI scans of the spine have no causal relationship to the patient’s symptoms. Even provocative discography which has been touted as a valid diagnostic test in the past has failed to live up to its expectation. Despite these drawbacks in our ability to make an accurate clinical diagnosis, there has been a steep increase in the number of patients who are treated with spinal fusion for non-specific low back pain over the last two decades. Chronic non-specific low back pain is a symptom and not a disease, hence logically surgery cannot be an effective mode of treatment for non-specific low back pain.Good quality medical literature which compares the clinical outcome of patients with chronic low back pain who were treated conservatively, with those treated with spinal fusion does not exit. There are two level 1 studies with a two to four years follow up which did such a comparison but these studies did not show superiority of surgical treatment over nonsurgical treatment. There is no doubt that spinal fusion can be associated with significant and sometimes serious medical complications including mortality.Despite the absence of good evidence to support the efficacy of spinal fusion for chronic low back pain, the rates of spinal fusion has rocketed in recent decades. This has raised concerns about conflicts of interest and unethical behaviour among healthcare providers. Accusations of kickbacks to spine surgeons from the medical devices industry have made headlines in major newspapers in the US in recent years. Another area of concern is the involvement of spine surgeons in the manufacture and distribution of spinal implants and this has created pernicious conflicts of interest leading to an increase in spinal fusions and bias in the doctors’ decision making process.Allegations of financial conflicts of interest and the fact that there isn’t sufficient scientific evidence to support the use of spinal fusion as a modality of treatment for chronic low back pain, should make us reconsider our indications for spinal fusion. The decision to do spinal fusion in the absence of clear indications may have future medico-legal implications and the conflicts of interest involved may run afoul of existing legislations in some countries.