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Försth P, Ólafsson G, Carlsson T, Frost A, Borgström F, Fritzell P, Öhagen P, Michaëlsson K, Sandén B. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med 2016; 374:1413-23. [PMID: 27074066 DOI: 10.1056/nejmoa1513721] [Citation(s) in RCA: 509] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials. METHODS We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up. RESULTS There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P=0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompression-alone group, P=0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P<0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group. CONCLUSIONS Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone. (Funded by an Uppsala institutional Avtal om Läkarutbildning och Forskning [Agreement concerning Cooperation on Medical Education and Research] and others; Swedish Spinal Stenosis Study ClinicalTrials.gov number, NCT01994512.).
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Affiliation(s)
- Peter Försth
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Gylfi Ólafsson
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Thomas Carlsson
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Anders Frost
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Fredrik Borgström
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Peter Fritzell
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Patrik Öhagen
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Karl Michaëlsson
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
| | - Bengt Sandén
- From the Department of Surgical Sciences, Division of Orthopedics (P. Försth, T.C., P. Fritzell, K.M., B.S.), and the Uppsala Clinical Research Center (P.Ö., K.M.), Uppsala University, Uppsala, Stockholm Spine Center (P. Försth, A.F.), the Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet (G.Ó., F.B.), and Quantify Research (G.Ó., F.B.), Stockholm, and Futurum-Academy for Health and Care, Neuro-orthopedic Center, Ryhov (P. Fritzell) - all in Sweden
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Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JVCE, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VKH, Barker FG, Benzel EC. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med 2016; 374:1424-34. [PMID: 27074067 DOI: 10.1056/nejmoa1508788] [Citation(s) in RCA: 516] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. METHODS In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years. RESULTS A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05). CONCLUSIONS Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.).
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Affiliation(s)
- Zoher Ghogawala
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - James Dziura
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - William E Butler
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Feng Dai
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Norma Terrin
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Subu N Magge
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Jean-Valery C E Coumans
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - J Fred Harrington
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Sepideh Amin-Hanjani
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - J Sanford Schwartz
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Volker K H Sonntag
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Fred G Barker
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Edward C Benzel
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
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