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Treatment of Degenerative Lumbar Spondylolisthesis With Fusion or Decompression Alone Results in Similar Rates of Reoperation at 5 Years. Clin Spine Surg 2018; 31:E74-E79. [PMID: 28671881 DOI: 10.1097/bsd.0000000000000564] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Population-based analysis of administrative discharge records from California, Florida, and New York inpatient, ambulatory, and emergency department settings between 2005 and 2011, utilizing Healthcare Cost and Utilization Project data. OBJECTIVE We aimed to compare, and characterize rates of reoperation and readmission among patients with degenerative spondylolisthesis treated with surgical decompression alone versus fusion. SUMMARY OF BACKGROUND DATA Degenerative lumbar spondylolisthesis with stenosis can be treated by decompression with or without fusion. Fusion has traditionally been preferred. We hypothesized that rates of reoperation after decompression alone would be higher than after fusion. MATERIALS AND METHODS We undertook a population-based analysis of administrative discharge records from California, Florida, and New York inpatient, ambulatory, and emergency department settings between 2005 and 2011, with Healthcare Cost and Utilization Project data. We identified all patients who had degenerative spondylolisthesis who were treated with decompression alone or with fusion and compared their rates of reoperation at 1, 3, and 5 years from the index operation. We used descriptive statistics and a hierarchical logistic regression model to generate risk-adjusted odds of all-cause readmissions. RESULTS Our study consisted of 75,024 patients with spondylolisthesis; 6712 (8.95%) of them underwent decompression alone and 68,312 (91.05%) of them underwent fusion. Rates of reoperation were higher for decompression versus fusion at 1 year; 6.87% versus 5.53% (P≤0.001), but at 3 years; 13.86% versus 12.91% (P=0.18) and 5 years; 16.9% versus 17.7% (P=0.398) years rates of reoperation were not statistically different. Patients treated with decompression alone that had a second operation tended to have the operation sooner 512.6 versus 567.4 days (P=0.008). CONCLUSIONS Our study suggests that treatment of degenerative spondylolisthesis with fusion or decompression alone results in similar rates of reoperation at 5 years. This medium term data indicate that decompression alone may be a viable treatment for some patients with degenerative spondylolisthesis.
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452
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Outcomes of multisegmental transforaminal enlarged decompression plus posterior pedicle screw fixation for multilevel lumbar spinal canal stenosis associated with lumbar instability. Int J Surg 2018; 50:72-78. [PMID: 29329787 DOI: 10.1016/j.ijsu.2017.12.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/23/2017] [Accepted: 12/26/2017] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the clinical and radiologic results of multisegmental transforaminal enlarged decompression (TED) plus posterior pedicle screw fixation in the treatment of multilevel lumbar spinal canal stenosis (LSCS) with lumbar instability (MLSCSI). METHODS 113 patients with MLSCSI underwent surgery were recruited in this study. All patients were suffering from symptoms typical of degenerative LSCS and treated with either TED plus fusion (TEDF group) or conventional laminectomy plus fusion (CLF group). Clinical and radiologic parameters were evaluated. The clinical data, including Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), operative time, intraoperative blood loss, postoperative drainage, hospital stay, and the rate of postoperative complications, were assessed. With respect to radiologic parameters, mean disc height (MDH) and lumbar lordotic angle (LLA) were measured using plain radiographs. Patient satisfaction was evaluated according to the North American Spine Society (NASS) Outcome Questionnaire. RESULTS No serious complications occurred during the follow-up. The operative time was significantly shorter for TEDF group than for CLF group, and similar results were found with regard to the blood loss and postoperative drainage (p < .05). The improvements in ODI, leg and back VAS scores were observed in both groups after surgery and follow-up (P < .05). In the last follow-up, ODI and back VAS scores in TEDF group were significantly higher than those in CLF group (P < .05). Regarding radiologic variants, MDH and LLA were improved after operation for 3 months (P > .05) and were all well maintained in the final follow-up in both groups. Patients in TEDF group were more satisfied than patients in the CLF group (85.2% vs 76.9%, p = .092). CONCLUSIONS Satisfactory clinical and radiological outcomes can be achieved with the use of multisegmental TED plus lumbar fusion for the treatment of MLSCSI. This technique can reduce surgically induced instability and obviously improve the symptoms and signs of the patients, suggesting a safe and effective therapeutic procedure for MLSCSI.
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453
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Spoor JKH, Dallenga AHG, Gadjradj PS, de Klerk L, van Biezen FC, Bijvoet HWC, Harhangi BS. A novel noninstrumented surgical approach for foramen reconstruction for isthmic spondylolisthesis in patients with radiculopathy: preliminary clinical and radiographic outcomes. Neurosurg Focus 2018; 44:E7. [PMID: 29290136 DOI: 10.3171/2017.10.focus17571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The health care costs for instrumented spine surgery have increased dramatically in the last few decades. The authors present a novel noninstrumented surgical approach for patients with isthmic spondylolisthesis, with clinical and radiographic results. METHODS Charts of patients who underwent this technique were reviewed. The procedure consisted of nerve root decompression by reconstruction of the intervertebral foramen. This was achieved by removal of the pedicle followed by noninstrumented posterolateral fusion in which autologous bone graft from the right iliac crest was used. Outcomes regarding radicular complaints, bony fusion, progression of the slip, and complications were evaluated using patient history and radiographs obtained at follow-up intervals of 3-18 months after surgery. RESULTS A total of 58 patients with a mean age of 47 years were treated with this method. Partial removal of the pedicle was performed in 93.1% of the cases, whereas in 6.9% of the cases the entire pedicle was removed. The mean duration of surgery was 216.5 ± 54.5 minutes (range 91-340 minutes). The mean (± SD) duration of hospitalization was 10.1 ± 2.9 days (range 5-18 days). After 3 months of follow-up, 86% of the patients reported no leg pain, and this dropped to 81% at last follow-up. Radiographic follow-up showed bony fusion in 87.7% of the patients. At 1 year, 5 patients showed progression of the slip, which in 1 patient prompted a second operation within 1 year. No major complications occurred. CONCLUSIONS Treatment of isthmic spondylolisthesis by reconstruction of the intervertebral neuroforamen and posterolateral fusion in situ is a safe procedure and has comparable results with the existing techniques. Cost-effectiveness research comparing this technique to conventional instrumented fusion techniques is necessary to evaluate the merits for both patients and society.
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Affiliation(s)
| | | | - Pravesh S Gadjradj
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Leiden University Medical Center, Leiden; and
| | - Luuk de Klerk
- 3Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, The Netherlands
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454
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Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Knightly JJ, Park P, Fu KM, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Chotai S, DiGiorgio AM, Chan AY, Haid RW, Mummaneni PV. Women fare best following surgery for degenerative lumbar spondylolisthesis: a comparison of the most and least satisfied patients utilizing data from the Quality Outcomes Database. Neurosurg Focus 2018; 44:E3. [DOI: 10.3171/2017.10.focus17553] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe American Association of Neurological Surgeons launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data, to measure the safety and quality of neurosurgical procedures, including spinal surgery. Differing results from recent randomized controlled trials have established a need to clarify the groups that would most benefit from surgery for degenerative lumbar spondylolisthesis. In the present study, the authors compared patients who were the most and the least satisfied following surgery for degenerative lumbar spondylolisthesis.METHODSThis was a retrospective analysis of a prospective, national longitudinal registry including patients who had undergone surgery for grade 1 degenerative lumbar spondylolisthesis. The most and least satisfied patients were identified based on an answer of “1” and “4,” respectively, on the North American Spine Society (NASS) Satisfaction Questionnaire 12 months postoperatively. Baseline demographics, clinical variables, surgical parameters, and outcomes were collected. Patient-reported outcome measures, including the Numeric Rating Scale (NRS) for back pain, NRS for leg pain, Oswestry Disability Index (ODI), and EQ-5D (the EuroQol health survey), were administered at baseline and 3 and 12 months after treatment.RESULTSFour hundred seventy-seven patients underwent surgery for grade 1 degenerative lumbar spondylolisthesis in the period from July 2014 through December 2015. Two hundred fifty-five patients (53.5%) were the most satisfied and 26 (5.5%) were the least satisfied. Compared with the most satisfied patients, the least satisfied ones more often had coronary artery disease (CAD; 26.9% vs 12.2%, p = 0.04) and had higher body mass indices (32.9 ± 6.5 vs 30.0 ± 6.0 kg/m2, p = 0.02). In the multivariate analysis, female sex (OR 2.9, p = 0.02) was associated with the most satisfaction. Notably, the American Society of Anesthesiologists (ASA) class, smoking, psychiatric comorbidity, and employment status were not significantly associated with satisfaction. Although there were no significant differences at baseline, the most satisfied patients had significantly lower NRS back and leg pain and ODI scores and a greater EQ-5D score at 3 and 12 months postoperatively (p < 0.001 for all).CONCLUSIONSThis study revealed that some patient factors differ between those who report the most and those who report the least satisfaction after surgery for degenerative lumbar spondylolisthesis. Patients reporting the least satisfaction tended to have CAD or were obese. Female sex was associated with the most satisfaction when adjusting for potential covariates. These findings highlight several key factors that could aid in setting expectations for outcomes following surgery for degenerative lumbar spondylolisthesis.
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Affiliation(s)
- Andrew K. Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F. Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin T. Foley
- 5Department of Neurological Surgery, University of Tennessee Health Science Center, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Eric A. Potts
- 6Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Christopher I. Shaffrey
- 7Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mark E. Shaffrey
- 7Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Domagoj Coric
- 8Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery & Spine Associates, Charlotte, North Carolina
| | | | - Paul Park
- 10Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kai-Ming Fu
- 11Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L. Asher
- 8Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery & Spine Associates, Charlotte, North Carolina
| | - Michael S. Virk
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Silky Chotai
- 13Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - Anthony M. DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 14Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; and
| | - Alvin Y. Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Praveen V. Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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455
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Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons. World Neurosurg 2017; 111:e564-e572. [PMID: 29288862 DOI: 10.1016/j.wneu.2017.12.108] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. OBJECTIVE To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. METHODS 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S-BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. RESULTS There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S-BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. CONCLUSIONS Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.
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456
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Chen Z, Xie P, Feng F, Chhantyal K, Yang Y, Rong L. Decompression Alone Versus Decompression and Fusion for Lumbar Degenerative Spondylolisthesis: A Meta-Analysis. World Neurosurg 2017; 111:e165-e177. [PMID: 29248779 DOI: 10.1016/j.wneu.2017.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To compare the effectiveness and safety of decompression alone (D group) with decompression and fusion (DF group) for patients who were diagnosed with lumbar degenerative spondylolisthesis (LDS). METHODS Electronic databases were searched for relevant studies that compared decompression alone with decompression and fusion for LDS. Then, data extraction and quality assessment were conducted, and the extracted data were analyzed by using RevMan 5.3. We used the random effects model for studies that had heterogeneity between them, and for those without heterogeneity, the fixed model was used. RESULTS Four randomized controlled trials and 14 nonrandomized controlled studies involving 77,994 patients were included for this meta-analysis. Although the DF group was associated with a higher postoperative change score on a visual analog scale compared with the D group in terms of back (P = 0.02) and leg (P = 0.04), they failed to reach the minimum clinically important difference. Moreover, no significant differences were found in Oswestry Disability Index, European Quality of Life-5 Dimensions, Short-Form 36 physical and mental component summaries score, and patients' satisfaction (P > 0.05) between treatment groups. Complication rate and reoperation rate (P > 0.05) were similar in both groups. Data analysis also showed that the DF group was associated with longer operation time (P < 0.00001), more intraoperative blood loss (P < 0.00001), and longer length of hospital stay (P < 0.00001). CONCLUSIONS Among patients with LDS, decompression and fusion surgery did not yield better clinical outcomes than decompression alone surgery. Also, the complication rate and reoperation rate were comparable between treatment groups. However, patients who had undergone decompression alone had shorter operation time, less intraoperative blood loss, and shorter hospital stay.
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Affiliation(s)
- Zihao Chen
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Peigen Xie
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Feng Feng
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kishor Chhantyal
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yang Yang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Limin Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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457
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Kapetanakis S, Gkasdaris G, Thomaidis T, Charitoudis G, Nastoulis E, Givissis P. Postoperative Evaluation of Health-Related Quality-of-Life (HRQoL) of Patients With Lumbar Degenerative Spondylolisthesis After Instrumented Posterolateral Fusion (PLF): A prospective Study With a 2-Year Follow-Up. Open Orthop J 2017; 11:1423-1431. [PMID: 29387287 PMCID: PMC5748841 DOI: 10.2174/1874325001711011423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/13/2017] [Accepted: 11/23/2017] [Indexed: 11/22/2022] Open
Abstract
Background 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. Methods A group of 62 patients, 30 women (48,4%) and 32 men (51,6%) with mean age 56,73 (SD +/- 9,58) years old, were selected to participate in a 2-year follow-up. Their pain was assessed 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. Results 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 (physical functioning) and BP (bodily pain), presented statistically significant improvement within the follow up depicting a very similar improvement pattern to that of VAS. Conclusion 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.
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Affiliation(s)
- S Kapetanakis
- Spine Department and Deformities, Interbalkan Medical Center, Thessaloniki, Greece
| | - G Gkasdaris
- Spine Department and Deformities, Interbalkan Medical Center, Thessaloniki, Greece.,Papanikolaou Hospital, Thessaloniki, Greece
| | - T Thomaidis
- Spine Department and Deformities, Interbalkan Medical Center, Thessaloniki, Greece
| | - G Charitoudis
- Spine Department and Deformities, Interbalkan Medical Center, Thessaloniki, Greece
| | - E Nastoulis
- Spine Department and Deformities, Interbalkan Medical Center, Thessaloniki, Greece
| | - P Givissis
- First Orthopaedic Department of Aristotle University of Thessaloniki, Papanikolaou Hospital, Exohi, Thessaloniki, Greece
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458
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Cho JH, Joo YS, Lim C, Hwang CJ, Lee DH, Lee CS. Effect of one- or two-level posterior lumbar interbody fusion on global sagittal balance. Spine J 2017; 17:1794-1802. [PMID: 28579287 DOI: 10.1016/j.spinee.2017.05.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 04/18/2017] [Accepted: 05/30/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Sagittal imbalance is associated with poor clinical outcomes in patients with degenerative lumbar disease. However, there is no consensus on the impact of posterior lumbar interbody fusion (PLIF) on local and global sagittal balance. PURPOSE To reveal the effect of one- or two-level PLIF on global sagittal balance. DESIGN/SETTING A retrospective case-control study. PATIENTS SAMPLE This study included 88 patients who underwent a one- or two-level PLIF for spinal stenosis with spondylolisthesis. OUTCOME MEASURES Clinical and radiological parameters were measured pre- and postoperatively. METHODS All patients were followed up for >2 years. Clinical outcomes included a visual analog scale, Oswestry Disability Index, and EuroQol 5-dimension questionnaire (EQ-5D). Radiological parameters were measured using whole-spine standing lateral radiographs. Fusion, loosening, subsidence rates, and adverse events were also evaluated. Patients were divided into two groups according to their preoperative C7-S1 sagittal vertical axis (SVA): Group N: SVA≤5 cm vs Group I: SVA>5 cm; they were also divided according to postoperative changes in C7-S1 SVA. Clinical and radiological outcomes were compared between the groups. RESULTS All clinical outcomes and radiological parameters improved postoperatively. C7-S1 SVA improved (-1.6 cm) after L3-L5 fusion, but it was compromised (+3.6 cm) after L4-S1 fusion (p=.001). Preoperative demographic and clinical data showed no difference except in the anxiety or depression domain of EQ-5D. No differences were found in postoperative clinical outcomes. Lumbar lordosis, pelvic tilt, and thoracic kyphosis slightly improved in Group N, whereas C7-S1 SVA decreased from 9.5 cm to 3.8 cm (p<.001) in Group I. Furthermore, all sagittal parameters improved in Group I. On comparing the postoperative changes in C7-S1 SVA, we found that the decreasing trend in the postoperative C7-S1 SVA was related to a larger preoperative C7-S1 SVA (p=.030) and a more proximal level fusion (L3-L5 vs L4-S1, p=.033). CONCLUSIONS Global sagittal balance improved after short-level lumbar fusion surgery in patients having spinal stenosis with spondylolisthesis who showed preoperative sagittal imbalance. Restoration of sagittal balance predominantly occurred after L3-L4, L4-L5, or L3-L5 PLIF. However, no such restoration was observed after L5-S1 or L4-S1 PLIF. Thus, we could anticipate sagittal balance restoration after performing PLIF at L3-L4 or L4-L5 level. However, caution is required when planning for L5-S1 fusion if preoperative sagittal imbalance is present.
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Affiliation(s)
- Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea.
| | - Youn-Suk Joo
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea
| | - Cheongsu Lim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea
| | - Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43-88, Olympic-ro, SongPa-gu, Seoul, Korea
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459
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Schoenfeld AJ, Makanji H, Jiang W, Koehlmoos T, Bono CM, Haider AH. Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System? Clin Orthop Relat Res 2017; 475:2838-2844. [PMID: 28074438 PMCID: PMC5670044 DOI: 10.1007/s11999-017-5229-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner. Specifically, there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a fee-for-service system, irrespective of the underlying lumbar disorder being treated. QUESTIONS/PURPOSES (1) Were proportions of interbody fusions higher in the fee-for-service setting as opposed to the salaried Department of Defense setting? (2) Were the odds of interbody fusion increased in a fee-for-service setting after controlling for indications for surgery? METHODS Patients surgically treated for lumbar disc herniation, spinal stenosis, and spondylolisthesis (2006-2014) were identified. Patients were divided into two groups based on whether the surgery was performed in the fee-for-service setting (beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance) or at a Department of Defense facility (direct care). There were 28,344 patients in the entire study, 21,290 treated in fee-for-service and 7054 treated in Department of Defense facilities. Differences in the rates of fusion-based procedures, discectomy, and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in case-mix and surgical indication. RESULTS TRICARE beneficiaries treated for lumbar spinal disorders in the fee-for-service setting had higher odds of receiving interbody fusions (fee-for-service: 7267 of 21,290 [34%], direct care: 1539 of 7054 [22%], odds ratio [OR]: 1.25 [95% confidence interval 1.20-1.30], p < 0.001). Purchased care patients were more likely to receive interbody fusions for a diagnosis of disc herniation (adjusted OR 2.61 [2.36-2.89], p < 0.001) and for spinal stenosis (adjusted OR 1.39 [1.15-1.69], p < 0.001); however, there was no difference for patients with spondylolisthesis (adjusted OR 0.99 [0.84-1.16], p = 0.86). CONCLUSIONS The preferential use of interbody fusion procedures was higher in the fee-for-service setting irrespective of the underlying diagnosis. These results speak to the existence of provider inducement within the field of spine surgery. This reality portends poor performance for surgical practices and hospitals in Accountable Care Organizations and bundled payment programs in which provider inducement is allowed to persist. LEVEL OF EVIDENCE Level III, economic and decision analysis.
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Affiliation(s)
- Andrew J. Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Heeren Makanji
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Christopher M. Bono
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Adil H. Haider
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
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460
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Cloney M, Hopkins B, Dhillon E, Dahdaleh NS. Outcomes of thoracic discectomy: A single center retrospective series. J Clin Neurosci 2017; 48:128-132. [PMID: 29150080 DOI: 10.1016/j.jocn.2017.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/02/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Cloney
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States.
| | - Benjamin Hopkins
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Ekamjeet Dhillon
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
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461
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Arts MP, Wolfs JF, Kuijlen JM, de Ruiter GC. Minimally invasive surgery versus open surgery in the treatment of lumbar spondylolisthesis: study protocol of a multicentre, randomised controlled trial (MISOS trial). BMJ Open 2017; 7:e017882. [PMID: 29133325 PMCID: PMC5695319 DOI: 10.1136/bmjopen-2017-017882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Patients with symptomatic spondylolisthesis are frequently treated with nerve root decompression, in addition to pedicle screw fixation and interbody fusion. Minimally invasive approaches are gaining attention in recent years, although there is no clear evidence supporting the proclamation of minimally invasive spine surgery (MISS) being better than open surgery. We present the design of the MISOS (Minimal Invasive Surgery versus Open Surgery) trial on the effectiveness of MISS versus open surgery in patients with degenerative or spondylolytic spondylolisthesis. METHODS AND ANALYSIS All patients (age 18-75 years) with neurogenic claudication or radicular leg pain based on low-grade degenerative or spondylolytic spondylolisthesis with persistent complaints for at least 3 months are eligible. Patients will be randomised into mini-open decompression with bilateral interbody fusion with percutaneous pedicle screw fixation (MISS), or conventional surgery with decompression and instrumented fusion with pedicle screws and bilateral interbody fusion (open). The primary outcome measure is Visual Analogue Scale of self-reported low back pain. Secondary outcome measures include improvement of leg pain, Oswestry Disability Index, patients' perceived recovery, quality of life, resumption of work, complications, blood loss, length of hospital stay, incidence of reoperations and documentation of fusion. This study is designed as a multicentre, randomised controlled trial in which two surgical techniques are compared in a parallel group design. Based on a 20 mm difference of low back pain score at 6 weeks (power of 90%, assuming 8% loss to follow-up), a total of 184 patients will be needed. All analyses will be performed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethical Review Board Southwest Holland in August 2014 (registration number NL 49044.098.14) and subsequently approved by the board of all participating hospitals. Dissemination will include peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER NTR 4532, pre-results.
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Affiliation(s)
- Mark P Arts
- Department of Neurosurgery, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Jasper Fc Wolfs
- Department of Neurosurgery, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Jos Ma Kuijlen
- Department of Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Godard Cw de Ruiter
- Department of Neurosurgery, Haaglanden Medisch Centrum, Den Haag, The Netherlands
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462
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Staartjes VE, Schröder ML. Effectiveness of a Decision-Making Protocol for the Surgical Treatment of Lumbar Stenosis with Grade 1 Degenerative Spondylolisthesis. World Neurosurg 2017; 110:e355-e361. [PMID: 29133000 DOI: 10.1016/j.wneu.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Addition of fusion to decompression for stenosis with grade 1 degenerative spondylolisthesis is a controversial topic, and the question remains if fusion provides any benefit to the patient that warrants the increased health care utilization and perioperative morbidity. There is no consensus on indications for use of fusion over decompression alone. METHODS Patients received fusion or decompression according to a decision-making protocol based on their pattern of complaints, location of the compression, and facet angles and effusion as proven predictors of postoperative instability. Propensity score matching of patients was done for baseline data. RESULTS The study comprised 102 patients in 2 equally sized groups. No intergroup differences in numeric rating scale and Oswestry Disability Index were detected at any follow-up point (all P > 0.05). Duration of surgery, length of stay, estimated blood loss, and radiation doses were higher in the fusion group (all P < 0.001). Cumulative reoperation rate was similar with 6% for fusion and 8% for decompression (P > 0.05), as was the complication rate (8% vs. 6%, P > 0.05). Postoperative iatrogenic progression of spondylolisthesis requiring fusion surgery was seen in only 2% in the decompression group. CONCLUSIONS Use of a decision-making protocol led to a low rate of iatrogenically increased spondylolisthesis after decompression, while retaining outcomes. These data suggest that a decision-making protocol based on clinical history, location of nerve root compression, and proven radiologic predictors of postoperative instability assigns patients to fusion or decompression in a safe and effective manner.
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Affiliation(s)
- Victor E Staartjes
- Department of Neurosurgery, Bergman Clinics, Amsterdam, The Netherlands; Faculty of Medicine, University of Zurich, Zurich, Switzerland.
| | - Marc L Schröder
- Department of Neurosurgery, Bergman Clinics, Amsterdam, The Netherlands
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463
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Merali Z, Wilson JR. Explanatory Versus Pragmatic Trials: An Essential Concept in Study Design and Interpretation. Clin Spine Surg 2017; 30:404-406. [PMID: 29049130 DOI: 10.1097/bsd.0000000000000588] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Randomized clinical trials often represent the highest level of clinical evidence available to evaluate the efficacy of an intervention in clinical medicine. Although the process of randomization serves to maximize internal validity, the external validity, or generalizability, of such studies depends on several factors determined at the design phase of the trial including eligibility criteria, study setting, and outcomes of interest. In general, explanatory trials are optimized to demonstrate the efficacy of an intervention in a highly selected patient group; however, findings from these studies may not be generalizable to the larger clinical problem. In contrast, pragmatic trials attempt to understand the real-world benefit of an intervention by incorporating design elements that allow for greater generalizability and clinical applicability of study results. In this article we describe the explanatory-pragmatic continuum for clinical trials in greater detail. Further, a well-accepted tool for grading trials on this continuum is described, and applied, to 2 recently published trials pertaining to the surgical management of lumbar degenerative spondylolisthesis.
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Affiliation(s)
- Zamir Merali
- St. Michael's Hospital, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
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464
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Penn DL, Chi JH. Fusion Outcomes in Symptomatic Spondylolisthesis. Neurosurgery 2017; 81:N43-N44. [PMID: 29088466 DOI: 10.1093/neuros/nyx452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- David L Penn
- Department of Neurological Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
| | - John H Chi
- Department of Neurological Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
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465
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Choma TJ, Mroz TE, Goldstein CL, Arnold P, Shamji MF. Emerging Techniques in Degenerative Thoracolumbar Surgery. Neurosurgery 2017; 80:S55-S60. [PMID: 28350946 DOI: 10.1093/neuros/nyw079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 11/21/2016] [Indexed: 11/15/2022] Open
Abstract
There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.
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Affiliation(s)
- Theodore J Choma
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Miss-ouri
| | - Thomas E Mroz
- Departments of Orthopaedic and Neurological Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Paul Arnold
- Department of Neuro-surgery, University of Kansas, Kansas City, Kansas
| | - Mohammed F Shamji
- Department of Surgery, Uni-versity of Toronto, Toronto, Canada.,Divi-sion of Neurosurgery, Toronto Western Hospital, Toronto, Canada
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466
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Epstein NE, Hollingsworth RD. Nursing review of diagnosis and treatment of lumbar degenerative spondylolisthesis. Surg Neurol Int 2017; 8:246. [PMID: 29119044 PMCID: PMC5655753 DOI: 10.4103/sni.sni_276_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 11/13/2022] Open
Abstract
Background: In the lumbar spine, degenerative spondylolisthesis or degenerative (not traumatic) slippage of one vertebral body over another is divided into 4 grades – grade I (25%), grade II (50%), grade III (75%), and grade IV (100%). Dynamic X-rays, magnetic resonance (MR), and computed tomography (CT) scans document the slip secondary to arthritic changes of the facet joint plus stenosis, ossification of the yellow ligament, disc herniations, and synovial cysts. MR best demonstrates soft tissue pathology whereas CT better delineates ossific/calcified disease. Methods: Grade I degenerative spondylolisthesis, typically found at the L4–L5 level followed by L3–L4 and L5S1, is more common in females (ratio 2:1) over the age of 65. Symptoms include radiculopathy (root pain) and neurogenic claudication (e.g., pain with ambulation, requiring the patient to stop, rest, sit down). Symptoms/signs may include unilateral/bilateral radiculopathy and uni/multifocal motor, reflex, and sensory deficits in. Some may also present with a cauda equina syndrome (e.g., paraparesis/sphincter dysfunction). Results: Surgery for grade I-II spondylolisthesis may include laminectomy alone, laminectomy/noninstrumented fusion or with an instrumented fusion. Older patients with osteoporosis are more likely to have no fusion or a noninstrumented fusion. All fusions utilize autograft harvested from the laminectomy that may or may not be combined with a bone graft expander (to increase the fusion mass) combined with autogenous bone marrow aspirate. The fusion mass is placed over the transverse processes following decortication. Conclusions: Patients with multilevel spinal stenosis and degenerative spondylolisthesis may require decompressive lumbar laminectomies alone or in combination with noninstrumented or instrumented fusions.
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467
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Samuel AM, Moore HG, Cunningham ME. Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence. Curr Rev Musculoskelet Med 2017; 10:521-529. [PMID: 28994028 DOI: 10.1007/s12178-017-9442-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Current guidelines for the optimal treatment degenerative spondylolisthesis are weak and based on limited high-quality evidence. RECENT FINDINGS There is some moderate evidence that decompression alone may be a feasible treatment with lower surgical morbidity and similar outcomes to fusion when performed in a select population with a low-grade slip. Similarly, addition of interbody fusion may be best suited to a subset of patients with high-grade degenerative spondylolisthesis, although this remains controversial. Minimally invasive techniques are increasingly being utilized for both decompression and fusion surgeries with more and more studies showing similar outcomes and lower postoperative morbidity for patients. This will likely be an area of continued intense research. Finally, the role of spondylolisthesis reduction will likely be determined as further investigation into optimal sagittal balance and spinopelvic parameters is conducted. Future identification of ideal thresholds for sagittal vertical axis and slip angle that will prevent progression and reoperation will play an important role in surgical treatment planning. Current evidence supports surgical treatment of degenerative spondylolisthesis. While posterolateral spinal fusion remains the treatment of choice, the use of interbodies and decompressions without fusion may be efficacious in certain populations. However, additional high-quality evidence is needed, especially in newer areas of practice such as minimally invasive techniques and sagittal balance correction.
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Affiliation(s)
- Andre M Samuel
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Harold G Moore
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
| | - Matthew E Cunningham
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA
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468
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Minimally Invasive Computer Navigation-Assisted Endoscopic Transforaminal Interbody Fusion with Bilateral Decompression via a Unilateral Approach: Initial Clinical Experience at One-Year Follow-Up. World Neurosurg 2017; 106:291-299. [DOI: 10.1016/j.wneu.2017.06.174] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/25/2017] [Accepted: 06/28/2017] [Indexed: 11/20/2022]
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469
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Epidemiologic and Economic Burden Attributable to First Spinal Fusion Surgery: Analysis From an Italian Administrative Database. Spine (Phila Pa 1976) 2017; 42:1398-1404. [PMID: 28187074 DOI: 10.1097/brs.0000000000002118] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective large population based-study. OBJECTIVE Assessment of the epidemiologic trends and economic burden of first spinal fusions. SUMMARY OF BACKGROUND DATA No adequate data are available regarding the epidemiology of spinal fusion surgery and its economic impact in Europe. METHODS The study population was identified through a data warehouse (DENALI), which matches clinical and economic data of different Healthcare Administrative databases of the Italian Lombardy Region. The study population consisted of all subjects, resident in Lombardy, who, during the period January 2001 to December 2010, underwent spinal fusion surgery (ICD-9-CM codes: 81.04, 81.05, 81.06, 81.07, and 81.08). The first procedure was used as the index event. We estimated the incidence of first spinal fusion surgery, the population and surgery characteristics and the healthcare costs from the National Health Service's perspective. The analysis was performed for the entire population and divided into the main groups of diagnosis. RESULTS The analysis identified 17,772 [mean age (SD): 54.6 (14.5) years, 55.3% females] spinal fusion surgeries. Almost 67% of the patients suffered from a lumbar degenerative disease. The incidence rate of interventions increased from 11.5 to 18.5 per 100,000 person-year between 2001 and 2006, and was above 20.0 per 100,000 person-year in the last 4 years. The patients' mean age increased during the observational time period from 48.1 to 55.9 years; whereas the median hospital length of stay reported for the index event decreased. The average cost of the spinal fusion surgery increased during the observational period, from &OV0556; 4726 up to &OV0556; 9388. CONCLUSION The study showed an increasing incidence of spinal fusion surgery and costs from 2001 to 2010. These results can be used to better understand the epidemiological and economic burden of these interventions, and help to optimize the resources available considering the different clinical approaches accessible today. LEVEL OF EVIDENCE 4.
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470
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Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up. Spine (Phila Pa 1976) 2017; 42:E1077-E1086. [PMID: 28092340 DOI: 10.1097/brs.0000000000002068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective, multicenter cohort study. OBJECTIVE To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis. SUMMARY OF BACKGROUND DATA The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial. METHODS Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1-5, best-worst) and function (1-4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients' random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaike's Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms. RESULTS One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: -0.16-0.27) and -0.07 (95% confidence interval: -0.25-0.10) on SSM function, respectively. CONCLUSION Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more favorable outcome in both SSM scores as compared to decompression alone surgery. LEVEL OF EVIDENCE 3.
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471
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Nunley PD, Patel VV, Orndorff DG, Lavelle WF, Block JE, Geisler FH. Five-year durability of stand-alone interspinous process decompression for lumbar spinal stenosis. Clin Interv Aging 2017; 12:1409-1417. [PMID: 28919727 PMCID: PMC5593396 DOI: 10.2147/cia.s143503] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Lumbar spinal stenosis is the most common indication for spine surgery in older adults. Interspinous process decompression (IPD) using a stand-alone spacer that functions as an extension blocker offers a minimally invasive treatment option for intermittent neurogenic claudication associated with spinal stenosis. Methods This study evaluated the 5-year clinical outcomes for IPD (Superion®) from a randomized controlled US Food and Drug Administration (FDA) noninferiority trial. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf), and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI). Results At 5 years, 84% of patients (74 of 88) demonstrated clinical success on at least two of three ZCQ domains. Individual ZCQ domain success rates were 75% (66 of 88), 81% (71 of 88), and 90% (79 of 88) for ZCQss, ZCQpf, and ZCQps, respectively. Leg and back pain success rates were 80% (68 of 85) and 65% (55 of 85), respectively, and the success rate for ODI was 65% (57 of 88). Percentage improvements over baseline were 42%, 39%, 75%, 66%, and 58% for ZCQss, ZCQpf, leg and back pain VAS, and ODI, respectively (all P<0.001). Within-group effect sizes were classified as very large for four of five clinical outcomes (ie, >1.0; all P<0.0001). Seventy-five percent of IPD patients were free from reoperation, revision, or supplemental fixation at their index level at 5 years. Conclusion After 5 years of follow-up, IPD with a stand-alone spacer provides sustained clinical benefit.
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Affiliation(s)
| | - Vikas V Patel
- The Spine Center, University of Colorado Hospital, Denver, CO
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472
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Brox JI. Specific symptoms and signs of unstable back segments and curative surgery? Scand J Pain 2017; 16:211-212. [PMID: 28850404 DOI: 10.1016/j.sjpain.2016.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jens Ivar Brox
- Neck and Back Outpatient Clinic, Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; University of Oslo, Faculty of Medicine, Oslo, Norway.
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473
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Achieving Optimal Outcome for Degenerative Lumbar Spondylolisthesis: Randomized Controlled Trial Results. Neurosurgery 2017; 64:40-44. [DOI: 10.1093/neuros/nyx207] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 07/28/2017] [Indexed: 11/14/2022] Open
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474
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Campbell RC, Mobbs RJ, Lu VM, Xu J, Rao PJ, Phan K. Posterolateral Fusion Versus Interbody Fusion for Degenerative Spondylolisthesis: Systematic Review and Meta-Analysis. Global Spine J 2017; 7:482-490. [PMID: 28811993 PMCID: PMC5544162 DOI: 10.1177/2192568217701103] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE Current surgical management of degenerative spondylolisthesis (DS) involves decompression of the spinal canal followed by fusion with or without interbody. The additional functional and operative benefits derived from interbody inclusion has yet to be thoroughly established with a number of recent studies producing conflicting results. Thus, we aim to compare the functional and operative outcomes after fusion against interbody fusion in the treatment of DS. METHODS This systematic review of the literature comparing posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) outcomes in the treatment of DS was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic searches of 6 databases yielded 386 articles from database inception to July 2016, which were screening against established criteria for inclusion into this study. RESULTS A total of 6 studies, satisfied criteria and reported outcomes for 721 patients. Fusion alone was performed in 458 (63.5%) patients and interbody fusion was performed in 263 (36.5%) patients. Functional outcomes Oswestry Disability Index (P = .29) and visual analog scale (P = .13) were not statistically different between the 2 approaches. Furthermore, there was no significant inferiority between fusion alone and with interbody in terms of the operative outcomes of blood loss (P = .38), reoperation rate (P = .66), hospital stay (P = .96), complication rate (P = .78), or fusion rate (P = .15). CONCLUSIONS There was no statistically significant difference in functional and operative outcomes following fusion alone versus with interbody. Additional subgroup analysis of intrinsic DS features in future large, prospective, randomized controlled trials will improve the validity of these findings.
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Affiliation(s)
- Ryan C. Campbell
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Ralph J. Mobbs
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Victor M. Lu
- University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Xu
- Prince of Wales Private Hospital, Sydney, New South Wales, Australia,University of Sydney, Sydney, New South Wales, Australia
| | - Prashanth J. Rao
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia,University of Sydney, Sydney, New South Wales, Australia,Kevin Phan, NeuroSpine Surgery Research Group (NSURG), Level 7, Prince of Wales Private Hospital, Barker Street, Randwick, New South Wales, Australia.
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475
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Glassman SD. In Reply: Benefit of Transforaminal Lumbar Interbody Fusion vs Posterolateral Spinal Fusion in Lumbar Spine Disorders: A Propensity-Matched Analysis From the National Neurosurgical Quality and Outcomes Database Registry. Neurosurgery 2017; 81:E14-E15. [PMID: 28368481 DOI: 10.1093/neuros/nyx062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Steven D Glassman
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, Staff Surgeon, Norton Leatherman Spine Center, Louisville, Kentucky
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476
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Decompression plus fusion versus decompression alone for degenerative lumbar spondylolisthesis: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017. [PMID: 28647763 DOI: 10.1007/s00586-017-5200-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To compare the clinical effectiveness of decompression plus fusion and decompression alone for patients with degenerative lumbar spondylolisthesis, a systematic review and meta-analysis of all available evidence was performed. METHODS A search of the literature was conducted on PubMed/MEDLINE, EMBASE, and the Cochrane Collaboration Library. Relevant studies comparing decompression plus fusion and decompression alone were selected according to eligibility criteria. Predefined endpoints were extracted and meta-analyzed from the identified studies. RESULTS Four randomized controlled trials and 13 observational studies were eligible. The pooled data revealed that fusion was associated with significantly higher rates of satisfaction and lower leg pain scores when compared with decompression alone. However, fusion significantly increased the intraoperative blood loss, operative time and hospital stay. Both techniques had similar ODI, back pain scores, complication rate, and reoperation rate. CONCLUSIONS Based on the available evidence, decompression plus fusion maybe be better than decompression alone in the treatment of degenerative spondylolisthesis. Fusion had advantages of improvement of clinical satisfaction, as well as reduction of postoperative leg pain, with similar complication rate to decompression alone.
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477
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Affiliation(s)
- Theodore J Choma
- 1Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri 2Department of Orthopaedic Surgery, University of West Virginia, Morgantown, West Virginia
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478
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Berven S, DiGiorgio A. The Case for Deformity Correction in the Management of Radiculopathy with Concurrent Spinal Deformity. Neurosurg Clin N Am 2017; 28:341-347. [PMID: 28600009 DOI: 10.1016/j.nec.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of adult deformity varies significantly. Options range from nonoperative care to limited decompression to decompression with limited or extensive fusion. The appropriate surgical management is the approach that optimizes the likelihood of improvement in health-related quality of life, while limiting risks of complications and costs. Decompression alone is unreliable in the setting of significant deformity contributing to radiculopathy. Decompression with limited fusion is most appropriate for patients with age-appropriate global alignment of the spine, and decompression with more extensive fusion is most appropriate for patients with progressive deformity or with global sagittal or coronal malalignment.
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Affiliation(s)
- Sigurd Berven
- Department of Orthopaedic Surgery, UC San Francisco, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143-0728, USA.
| | - Anthony DiGiorgio
- Department of Orthopaedic Surgery, UC San Francisco, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143-0728, USA
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479
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Kim E, Chotai S, Stonko D, Wick J, Sielatycki A, Devin CJ. A retrospective review comparing two-year patient-reported outcomes, costs, and healthcare resource utilization for TLIF vs. PLF for single-level degenerative spondylolisthesis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:661-669. [PMID: 28585094 DOI: 10.1007/s00586-017-5142-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 04/18/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to compare patient-reported outcomes (PROs), morbidity, and costs of TLIF vs PLF to determine whether one treatment was superior in the setting of single-level degenerative spondylolisthesis. METHODS Patients undergoing TLIF or PLF for single-level spondylolisthesis were included for retrospective analysis. EQ-5D, ODI, SF-12 MCS/PCS, NRS-BP/LP scores were collected at baseline and 24 months after surgery. 90-day post-operative complications, revision surgery rates, and satisfaction scores were also collected. Two-year resource use was multiplied by unit costs based on Medicare payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Total cost was used to assess mean total 2-year cost per QALYs gained after surgery. RESULTS 62 and 37 patients underwent TLIF and PLF, respectively. Patients in the PLF group were older (p < 0.01). No significant differences were seen in baseline or 24-month PROs between the two groups. There was a significant improvement in all PROs from baseline to 24 months after surgery (p < 0.001). Both groups had similar rates of 90-day complications, revision surgery, satisfaction, and similar gain in QALYs and cost per QALYs gained. There was no significant difference in 24-month direct, indirect, and total cost. CONCLUSIONS Overall costs and health care utilization were similar in both the groups. Both TLIF and PLF for single-level degenerative spondylolisthesis provide improvement in disability, pain, quality of life, and general health.
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Affiliation(s)
- Elliott Kim
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Silky Chotai
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - David Stonko
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Joseph Wick
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Alex Sielatycki
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Clinton J Devin
- Department of Orthopaedic Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.
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Elsamadicy AA, Adogwa O, Warwick H, Sergesketter A, Lydon E, Shammas RL, Mehta AI, Vasquez RA, Cheng J, Bagley CA, Karikari IO. Increased 30-Day Complication Rates Associated with Laminectomy in 874 Adult Patients with Spinal Deformity Undergoing Elective Spinal Fusion: A Single Institutional Study. World Neurosurg 2017; 102:370-375. [DOI: 10.1016/j.wneu.2017.03.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/19/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
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Abstract
OBJECTIVES Intrathecal morphine (ITM) is an efficacious method of providing postoperative analgesia and reducing pain associated complications. Despite adoption in many surgical fields, ITM has yet to become a standard of care in lumbar spine surgery. Spine surgeons' reticence to make use of the technique may in part be attributed to concerns of precipitating a cerebrospinal fluid (CSF) leak. METHODS Herein we describe a method for oblique intrathecal injection during lumbar spine surgery to minimize risk of CSF leak. The dural sac is penetrated obliquely at a 30° angle to offset dural and arachnoid puncture sites. Oblique injection in instances of limited dural exposure is made possible by introducing a 60° bend to a standard 30-gauge needle. RESULTS The technique was applied for injection of ITM or placebo in 104 cases of lumbar surgery in the setting of a randomized controlled trial. Injection was not performed in two cases (2/104, 1.9%) following preinjection dural tear. In the remaining 102 cases no instances of postoperative CSF leakage attributable to oblique intrathecal injection occurred. Three cases (3/102, 2.9%) of transient CSF leakage were observed immediately following intrathecal injection with no associated sequelae or requirement for postsurgical intervention. In two cases, the observed leak was repaired by sealing with fibrin glue, whereas in a single case the leak was self-limited requiring no intervention. CONCLUSIONS Oblique dural puncture was not associated with increased incidence of postoperative CSF leakage. This safe and reliable method of delivery of ITM should therefore be routinely considered in lumbar spine surgery.
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482
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Nunley PD, Patel VV, Orndorff DG, Lavelle WF, Block JE, Geisler FH. Superion Interspinous Spacer Treatment of Moderate Spinal Stenosis: 4-Year Results. World Neurosurg 2017; 104:279-283. [PMID: 28479526 DOI: 10.1016/j.wneu.2017.04.163] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine 4-year clinical outcomes in patients with moderate lumbar spinal stenosis treated with minimally invasive stand-alone interspinous process decompression using the Superion device. METHODS The 4-year Superion data were extracted from a randomized, controlled Food and Drug Administration investigational device exemption trial. Patients with intermittent neurogenic claudication relieved with back flexion who failed at least 6 months of nonsurgical management were enrolled. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf) and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI). At 4-year follow-up, 89 of the 122 patients (73%) provided complete clinical outcome evaluations. RESULTS At 4 years after index procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success on at least 2 of 3 ZCQ domains. Individual component responder rates were 83% (74/89), 79% (70/89), and 87% (77/89) for ZCQss, ZCQpf, and ZCQps; 78% (67/86) and 66% (57/86) for leg and back pain VAS; and 62% (55/89) for ODI. Patients with Superion also demonstrated percentage improvements over baseline of 41%, 40%, 73%, 69%, and 61% for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI. Within-group effect sizes all were classified as very large (>1.0): 1.49, 1.65, 1.42, 1.12, and 1.46 for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI. CONCLUSIONS Minimally invasive implantation of the Superion device provides long-term, durable relief of symptoms of intermittent neurogenic claudication for patients with moderate lumbar spinal stenosis.
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Affiliation(s)
| | - Vikas V Patel
- The Spine Center, University of Colorado Hospital, Denver, Colorado, USA
| | | | | | - Jon E Block
- Private practice, San Francisco, California, USA.
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483
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Chang W, Yuwen P, Zhu Y, Wei N, Feng C, Zhang Y, Chen W. Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2017; 137:637-650. [PMID: 28361467 DOI: 10.1007/s00402-017-2685-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The debate on efficacy of fusion added to decompression for lumbar spinal stenosis (LSS) is ongoing. No meta-analysis has compared the effectiveness of decompression versus decompression plus fusion in treating patients with LSS. METHODS A literature search was performed in the Web of Science, PubMed, Embase, and Springer databases from 1970 to 2016. Relevant references were selected and the included studies were manually reviewed. We included trials evaluating decompression surgery compared to decompression plus fusion surgery in treating patients with LSS. The primary outcomes analyzed were back pain, leg pain, Oswestry Disability Index scores (ODI), the quality-of-life EuroQol-5 Dimensions (EQ-5D), duration of operation, intraoperative blood loss, length of hospital stay, major complications, walking ability, number of reoperation, and finally clinically excellent and good rates. Data analysis was conducted using the Review Manager 5.2 software. RESULTS Fifteen studies involving 17,785 patients with LSS were included. The overall effect mean difference (MD) (95% CI) in the differences between pre- and post-operative back pain, leg pain, operative time, intraoperative blood loss, and length of stay were 0.04 (-0.36, 0.44), 0.69 (-0.38, 1.76), -2.04 (-3.12, -0.96), -3.96 (-6.64, -1.27) and -4.21 (-10.03, 1.62) (z = 0.18, 1.26, 3.71, 2.89 and 1.41, respectively; P = 0.86, 0.55, 0.0002, 0.004 and 0.16, respectively) in random effects models. The overall effect MD (95% CI) in ODI, EQ-5D, and walking ability were 0.43 (-1.15, 2.00), 0.01 (-0.01, 0.03) and 0.04 (-0.49, 0.57) (z = 0.52, 1.16 and 0.15, respectively; P = 0.59, 0.24 and 0.88, respectively) in fixed effects models. The overall effect odds ratio (OR) (95% CI) of major complications, number of reoperations, and clinically excellent and good rates between the two groups were 0.70 (0.60, 0.81), 1.04 (0.90, 1.19) and 0.31 (0.06, 1.59) (z = 4.63, 0.53 and 1.40, respectively; P < 0.00001, 0.60 and 0.16, respectively). Our study reveals no difference in the effectiveness between the two surgical techniques. CONCLUSIONS The additional fusion in the management of LSS yielded no clinical improvements over decompression alone within a 2-year follow-up period. But fusion resulted in a longer duration of operation, more blood loss, and a higher risk of complications. Therefore, the appropriate surgical protocol for LSS should be discussed further.
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Affiliation(s)
- Wenli Chang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Peizhi Yuwen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Yanbing Zhu
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Ning Wei
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Chen Feng
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Yingze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China
| | - Wei Chen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, NO. 139 Ziqiang Road, Shijiazhuang, 050051, People's Republic of China.
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Lønne G, Schoenfeld AJ, Cha TD, Nygaard ØP, Zwart JAH, Solberg T. Variation in selection criteria and approaches to surgery for Lumbar Spinal Stenosis among patients treated in Boston and Norway. Clin Neurol Neurosurg 2017; 156:77-82. [DOI: 10.1016/j.clineuro.2017.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 02/14/2017] [Accepted: 03/11/2017] [Indexed: 02/08/2023]
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Phan K, Teng I, Schultz K, Mobbs RJ. Treatment of Lumbar Spinal Stenosis by Microscopic Unilateral Laminectomy for Bilateral Decompression: A Technical Note. Orthop Surg 2017; 9:241-246. [PMID: 28547809 PMCID: PMC6584433 DOI: 10.1111/os.12335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 12/20/2016] [Indexed: 11/26/2022] Open
Abstract
Lumbar spinal stenosis is typically a degenerative condition that leads to compression of the spinal canal and lateral recess, resulting in leg pain and walking disability. Surgical management is indicated after failure of non-surgical management or rapidly worsening neurological impairment. The traditional approach is a laminectomy with foraminotomy and partial facetectomy but a newer minimally invasive option, unilateral laminectomy for bilateral decompression (ULBD), seems to demonstrate the better postoperative outcomes due to its unilateral exposure. ULBD involves a midline incision, opening the thoracolumbar fascia, retracting the paravertebral muscles unilaterally, then a hemilaminectomy, flavectomy, and decompression of the spinal canal with foraminotomy or partial facetectomy. The clinical decision on which side to approach spinal stenosis with ULBD has not been discussed in the literature. We have come up with an algorithm to decide which side to approach for ULBD based on position of spinous process and angulation, side of maximal compression, and surgeon handedness.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private HospitalRandwickAustralia
- Faculty of MedicineUniversity of SydneySydneyAustralia
| | - Ian Teng
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private HospitalRandwickAustralia
| | | | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private HospitalRandwickAustralia
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486
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Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. SCOLIOSIS AND SPINAL DISORDERS 2017; 12:14. [PMID: 28435906 PMCID: PMC5395891 DOI: 10.1186/s13013-017-0121-3] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/04/2017] [Indexed: 12/12/2022]
Abstract
Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.
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Affiliation(s)
- Arnold YL Wong
- Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, SAR China
| | - Jaro Karppinen
- Medical Research Center Oulu, Department of Physical and Rehabilitation Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
| | - Dino Samartzis
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR China
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Lagman C, Chung LK, Macyszyn L, Choy W, Smith ZA, Dahdaleh NS, Bohnen AM, Cho JM, Colen CB, Duckworth E, Germanwala AV, Kan P, Khalessi AA, Kim CY, Lam S, Li G, Lim M, Sherman JH, Wang VY, Zada G, Yang I. Neurosurgery concepts: Key perspectives on imaging characteristics of spinal metastases, surgery for low back pain, anesthesia for disc surgery, and laminectomy versus laminectomy and fusion for lumbar spondylolisthesis. Surg Neurol Int 2017; 8:9. [PMID: 28217388 PMCID: PMC5288991 DOI: 10.4103/2152-7806.198736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 10/20/2016] [Indexed: 01/14/2023] Open
Affiliation(s)
- Carlito Lagman
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
| | - Lawrance K Chung
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
| | - Luke Macyszyn
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
| | - Winward Choy
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
| | - Zachary A Smith
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Nader S Dahdaleh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Angela M Bohnen
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Jin M Cho
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, South Korea
| | - Chaim B Colen
- Department of Neurosurgery, Beaumont Hospital, Grosse Pointe, MI, United States
| | - Edward Duckworth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Chicago, Stritch School of Medicine, Illinois, United States
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego School of Medicine, San Diego, California, United States
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Korea
| | - Sandi Lam
- Texas Children's Hospital, Houston, Texas, United States
| | - Gordon Li
- Department of Neurosurgery, Stanford School of Medicine, Stanford, California, United States
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Jonathan H Sherman
- Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington DC, United States
| | - Vincent Y Wang
- Seton Brain and Spine Institute Neurosurgery, Kyle, Texas, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
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Theologis AA, Jain D, Ames CP, Pekmezci M. Circumferential fusion for degenerative lumbar spondylolisthesis complicated by distal junctional grade 4 spondylolisthesis in the sub-acute post-operative setting. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:3075-3081. [PMID: 28204925 DOI: 10.1007/s00586-017-4976-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/13/2016] [Accepted: 01/23/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Surgical management for lumbar stenosis is generally safe and provides significant improvements in pain, disability, and function. Successful lumbar decompression hinges on removing an appropriate amount of lamina and other compressive pathology in the lateral recess. Too little bony decompression can result in persistent pain and disability, while over resection of the pars and/or facets may jeopardize spinal stability. CASE REPORT In this unique report, we present for the first time an acute iatrogenic grade 4 L5-S1 spondylolisthesis distal to a L3-5 laminectomy and circumferential instrumented fusion due to bilateral iatrogenic L5 pars fractures and its management and clinical outcomes after revision operation. The patient presented with worsening pain, neurologic compromise, and severe sagittal imbalance. The iatrogenic, high-grade spondylolisthesis was urgently addressed with a L5-S1 anterior lumbar interbody fusion and extension of posterior instrumentation to the pelvis, which resulted in considerable pain relief, resolution of neurologic deficits, and reconstitution of acceptable sagittal imbalance. CONCLUSION All attempts during a lumbar decompression should be made to prevent iatrogenic pars fractures, as they may result in severe sagittal imbalance, neurologic compromise, and persistent disability. Iatrogenic, high-grade L5-S1 spondylolisthesis can be successfully treated with reduction using circumferential fusion of the lumbosacral junction.
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Affiliation(s)
- Alexander A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Avenue, MU West 3rd Floor, San Francisco, CA, 94143, USA.
| | - Deeptee Jain
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Avenue, MU West 3rd Floor, San Francisco, CA, 94143, USA
| | | | - Murat Pekmezci
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Avenue, MU West 3rd Floor, San Francisco, CA, 94143, USA
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492
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Barz C, Melloh M, Staub LP, Lord SJ, Merk HR, Barz T. Reversibility of nerve root sedimentation sign in lumbar spinal stenosis patients after decompression surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2573-2580. [DOI: 10.1007/s00586-017-4962-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 12/02/2016] [Accepted: 01/18/2017] [Indexed: 11/30/2022]
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493
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Ghogawala Z, Resnick DK, Glassman SD, Dziura J, Shaffrey CI, Mummaneni PV. Randomized controlled trials for degenerative lumbar spondylolisthesis: which patients benefit from lumbar fusion? J Neurosurg Spine 2017; 26:260-266. [PMID: 27661562 DOI: 10.3171/2016.8.spine16716] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zoher Ghogawala
- Alan L. and Jacqueline B. Stuart Spine Research Center, Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Daniel K Resnick
- Department of Neurosurgery, University of Wisconsin, Madison, WI
| | - Steven D Glassman
- Department of Orthopedic Surgery, University of Louisville School of Medicine, Louisville, KY
| | - James Dziura
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | | | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA
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494
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Shin EK, Kim CH, Chung CK, Choi Y, Yim D, Jung W, Park SB, Moon JH, Heo W, Kim SM. Sagittal imbalance in patients with lumbar spinal stenosis and outcomes after simple decompression surgery. Spine J 2017; 17:175-182. [PMID: 27546526 DOI: 10.1016/j.spinee.2016.08.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/21/2016] [Accepted: 08/16/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) is the most common lumbar degenerative disease, and sagittal imbalance is uncommon. Forward-bending posture, which is primarily caused by buckling of the ligamentum flavum, may be improved via simple decompression surgery. PURPOSE The objectives of this study were to identify the risk factors for sagittal imbalance and to describe the outcomes of simple decompression surgery. STUDY DESIGN This is a retrospective nested case-control study PATIENT SAMPLE: This was a retrospective study that included 83 consecutive patients (M:F=46:37; mean age, 68.5±7.7 years) who underwent decompression surgery and a minimum of 12 months of follow-up. OUTCOME MEASURES The primary end point was normalization of sagittal imbalance after decompression surgery. METHODS Sagittal imbalance was defined as a C7 sagittal vertical axis (SVA) ≥40 mm on a 36-inch-long lateral whole spine radiograph. Logistic regression analysis was used to identify the risk factors for sagittal imbalance. Bilateral decompression was performed via a unilateral approach with a tubular retractor. The SVA was measured on serial radiographs performed 1, 3, 6, and 12 months postoperatively. The prognostic factors for sagittal balance recovery were determined based on various clinical and radiological parameters. RESULTS Sagittal imbalance was observed in 54% (45/83) of patients, and its risk factors were old age and a large mismatch between pelvic incidence and lumbar lordosis. The 1-year normalization rate was 73% after decompression surgery, and the median time to normalization was 1 to 3 months. Patients who did not experience SVA normalization exhibited low thoracic kyphosis (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02-1.10) (p<.01) and spondylolisthesis (HR, 0.33; 95% CI, 0.17-0.61) before surgery. CONCLUSIONS Sagittal imbalance was observed in more than 50% of LSS patients, but this imbalance was correctable via simple decompression surgery in 70% of patients.
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Affiliation(s)
- E Kyung Shin
- Department of Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea; Clinical Research Institute, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea; Clinical Research Institute, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, 56-1, Sillim-dong, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Yunhee Choi
- Medical Research Collaborating Center, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Dahae Yim
- Medical Research Collaborating Center, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Whei Jung
- Department of Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea; Clinical Research Institute, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Boramae, Medical Center 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung Hyeon Moon
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Won Heo
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Sung-Mi Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Abstract
A patient underwent C2-T2 decompression and fusion with excessive intraoperative bleeding and no clear source. The patient denied the use of blood-thinning medications, but had consumed the equivalent of 12 g garlic daily in the days leading up to the surgery. He was treated with desmopressin acetate (DDAVP) and cryoprecipitate with adequate control of bleeding. Garlic is known to have an antiplatelet effect, although the dose range necessary to create a bleeding abnormality has not yet been well described nor has the effect of taking garlic with sertraline or other agents with an established or potential effect on coagulation.
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Affiliation(s)
- Anna Woodbury
- From the *Department of Anesthesiology, Veterans Affairs Medical Center-Atlanta, Decatur, Georgia; and †Department of Anesthesiology, Emory University, Atlanta, Georgia
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Guyer R, Musacchio M, Cammisa FP, Lorio MP. ISASS Recommendations/Coverage Criteria for Decompression with Interlaminar Stabilization - Coverage Indications, Limitations, and/or Medical Necessity. Int J Spine Surg 2016; 10:41. [PMID: 28377855 DOI: 10.14444/3041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Káplár Z, Wáng YXJ. South Korean degenerative spondylolisthesis patients had surgical treatment at earlier age than Japanese, American, and European patients: a published literature observation. Quant Imaging Med Surg 2016; 6:785-790. [PMID: 28090453 DOI: 10.21037/qims.2016.11.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Zoltán Káplár
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong, China
| | - Yì-Xiáng J Wáng
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong, China
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499
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Machado GC, Ferreira PH, Yoo RIJ, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev 2016; 11:CD012421. [PMID: 27801521 PMCID: PMC6464992 DOI: 10.1002/14651858.cd012421] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear. OBJECTIVES To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates. SEARCH METHODS Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews. SELECTION CRITERIA This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'. AUTHORS' CONCLUSIONS The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.
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Affiliation(s)
- Gustavo C Machado
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Rafael IJ Yoo
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW AustraliaIngham Institute for Applied Medical ResearchElizabeth StreetLiverpoolNew South WalesAustralia2170
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
| | - Maurits W van Tulder
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
| | - Magdalena Rzewuska
- University of São PauloDepartment of Social Medicine, Faculty of MedicineAv. Bandeirantes, 3900 ‐ Monte AlegreRibeirão PretoSão PauloBrazil
| | - Christopher G Maher
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyThe George Institute for Global Health & Institute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
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