A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis

Stability of SF-36 profiles between 2007 and 2016: A study of 27,302 patients surgically treated for lumbar spine diseases

Background

Previous studies have shown that patients with different lumbar spine diseases report different SF-36 profiles, but data on the stability of the SF-36 profiles are limited. The primary aim of the current study was to evaluate the stability of the SF-36 profile for lumbar spine diseases.

Methods

Patients, surgically treated between 2007 and 2016 for three lumbar spine diseases, lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS), LSS without DS, and lumbar disk herniations (LDH), were identified in the Swedish spine register. Preoperative and 1 year postoperative SF-36 data for a total of 27,302 procedures were available for analysis. The stability of the SF-36 profiles over the 10-year period was evaluated using graphical exploration, linear regression, difference in means, and 95% confidence intervals. The responsiveness of the SF-36 domains to surgical treatment was evaluated using the standardized response mean (SRM).

Results

LSS and LDH have different SF-36 profiles. LSS with DS and LSS without DS have similar SF-36 profiles. The preoperative and the 1 year postoperative SF-36 profiles were stable from 2007 to 2016 for all three diagnoses. There were no major changes in the effect size of change (SRM) during the study period for all three diagnoses. For LSS with DS, the number of fusions peaked in 2010 and then decreased. The postoperative SF-36 profiles for LSS with DS were unaffected by changes in surgical treatment trends.

Conclusions

Patients with lumbar spinal stenosis and lumbar disk herniations have different SF-36 profiles. Concomitant degenerative spondylolisthesis had no impact on the SF-36 profile of lumbar spinal stenosis. Adding fusion to the decompression did not alter the postoperative SF-36 profile of lumbar spinal stenosis. The SF-36 health profiles are stable from a 10 years perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01999-7.

Responsiveness of the Zurich Claudication Questionnaire, the Oswestry Disability Index, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, the 8-Item Short Form Health Survey, and the Euroqol 5 dimensions 5 level in the assessment of patients with lumbar spinal stenosis

PURPOSE

To assess the responsiveness of the Zurich Claudication Questionnaire (ZCQ), the Oswestry Disability Index, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, the visual analog scale (VAS), the 8-Item Short Form Health Survey (SF-8), and the EuroQol 5 dimensions 5 level as methods of assessing outcomes of surgery for lumbar spinal stenosis.

METHODS

We analyzed 218 patients who had undergone lumbar surgery for spinal stenosis and completed one year of follow-up. The internal responsiveness of each questionnaire and any domains was assessed by the effect size and standardized response mean. External responsiveness was assessed by the Spearman rank correlation coefficient and the receiver operating characteristics (ROC) curve.

RESULTS

The most responsive assessments were "symptom severity" and "physical function" on the ZCQ, "walking ability" on the JOABPEQ, "leg pain" on the VAS, and "social function" on the JOABPEQ. The moderately responsive assessments were the physical component summary on the SF-8, the ODI, the EQ5D-5L, "low back pain" on the JOABPEQ, and "leg numbness" on the VAS. The least responsive assessments were "low back pain" on the VAS, "mental health" and "lumbar function" on the JOABPEQ, and the mental component summary on the SF-8.

CONCLUSIONS

Because of its high responsiveness, "symptom severity" on the ZCQ is recommended as a primary tool for assessing outcome when designing prospective studies for lumbar spinal stenosis.

Neurosurgery in a patient with severe hemophilia B: an experience using eftrenonacog alfa as perioperative management

Extended half‐life FIX (EHL‐FIX) concentrates have been developed with the purpose of reducing the frequency of infusions in patients with severe or moderate hemophilia B. We describe the case of a 63‐year‐old patient with severe hemophilia B (sHB) treated with FIX‐Fc fusion protein (rFIXFc) who underwent neurosurgery.

Hemophilia patients may need surgical interventions for complications either related or not to their coagulopathy. Real‐life experience is still limited using eftrenonacog alfa. This case demonstrates that it is an effective and safe treatment option.

The effectiveness of percutaneous endoscopic decompression compared with open decompression and fusion for lumbar spinal stenosis: protocol for a multicenter, prospective, cohort study

Background

Lumbar spinal stenosis (LSS) is one of the most frequent indications for spine surgery. Open decompression and fusion surgery was the most common treatment and used to be regarded as the golden standard treatment for LSS. In recent years, percutaneous endoscopic decompression surgery was also used for LSS. However, the effectiveness and safety of percutaneous endoscopic decompression in the treatment of LSS have not been supported by high-level evidence. Our aim is to 1) compare the effectiveness of percutaneous endoscopic decompression surgery and open decompression and fusion for the treatment of LSS. 2) Investigate the prognosis risk factors for LSS. 3) Evaluate the influence of percutaneous endoscopic decompression for the stability of operative level, and degeneration of adjacent level.

Methods

It’s a prospective, multicenter cohort study. The study is performed at 4 centers in Beijing. This study plans to enroll 600 LSS patients (300 patients in the percutaneous endoscopic decompression group, and 300 patients in the open decompression and fusion group). The demographic variables, healthcare variables, symptom related variables, clinical assessment (Visual analogue score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association score (JOA)), and radiological assessment (dynamic X-ray, CT, MRI) will be collected at baseline visit. Patients will follow up at 3, 6, 12 months. The primary outcome is the difference of improvement of ODI between baseline and 12-month follow-up between the two groups. The secondary outcome is the score changes of preoperative and postoperative VAS, the recovery rate of JOA, MacNab criteria, patient satisfaction, degeneration grade of adjacent level, ROM of operative level and adjacent level, complication rate.

Discussion

In this study, we propose to conduct a prospective registry study to address the major controversies of LSS decompression under percutaneous spinal endoscopy, and investigate the clinical efficacy and safety of percutaneous endoscopic decompression and open decompression in the treatment of LSS.

Trial registration

This study has been registered on clinicaltrials.gov in January 15, 2020 (NCT04254757). (SPIRIT 2a).

Long-Term Outcomes After Minimally Invasive Bilateral or Unilateral Laminotomy for Degenerative Lumbar Spinal Stenosis: A Minimum 10-Year Follow-Up Study

OBJECTIVE

The optimal surgical procedure for minimal surgical intervention in symptomatic degenerative lumbar spinal stenosis (DLSS) is unknown. This article presents a method of minimally invasive decompression alone and reports the long-term outcomes and complications of patients treated with minimally invasive bilateral or unilateral laminotomy decompression performed by one surgeon.

METHODS

Patients with DLSS who underwent minimally invasive laminotomy decompression alone from March 2008 to October 2010 were included in the study, and 106 patients were followed up for at least 10 years. Clinical outcomes were assessed by Japanese Orthopedic Association, Oswestry Disability Index, and visual analog scale for back pain scores, and changes in walking tolerance and leg numbness were evaluated. Complications were recorded.

RESULTS

A total of 106 patients who met the inclusion and exclusion criteria were included in the study (mean age = 64 years, range = 43-83). The Japanese Orthopedic Association, Oswestry Disability Index, and visual analog scale back pain scores of patients significantly changed between before surgery and at subsequent follow-up (P < 0.001). The walking tolerance and leg numbness of patients significantly improved (P < 0.001), and these functions were well maintained during follow-up. Complications included intraoperative dural tears (n = 5), a wound infection (n = 1), deep vein thrombosis (n = 1), and nerve root lesions on the asymptomatic side (n = 2), all of which recovered within 3 months.

CONCLUSIONS

Minimally invasive laminotomy decompression is an effective procedure and achieves beneficial long-term clinical results for DLSS.

Clinical Evaluation of Surgery for Single-Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta-Analysis

To compare the efficacy and safety of different surgical procedures for patients with single‐segment lumbar spinal stenosis (LSS), Bayesian network meta‐analysis (NMA) was conducted in this study. Randomized controlled trials (RCTs) which reported 2 years' results after surgery were searched from PubMed, Embase, and Cochrane Register of Controlled Trials up to February 2021. Eligible RCTs that contained at least two of the following surgical procedures, bilateral decompression via the unilateral approach (BDUL), decompression with conventional laminectomy (CL), decompression with fusion (DF), endoscopic decompression (ED), interspinous process devices only (IPDs), decompression with interlaminar stabilization (DILS), decompression with lumbar spinal process‐splitting laminectomy (LSPSL), and minimally invasive tubular decompression (MTD), would be included after screening based on the inclusion and exclusion criteria. The primary outcome was Oswestry Disability Index (ODI). Twenty eligible RCTs were included, with a total of 2201 patients enrolled. The NMA showed that the following surgical procedures ranked first (surface under the cumulative ranking) when compared with CL and DF: DILS for ODI (SUCRA 87.8%); LSPSL for back pain (95%); and MTD for leg pain (95.6%). MTD ranked among the top three surgical procedures for most outcomes. The quality of the synthesized evidence was low according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. DILS, LSPSL, MTD, IPDs, and ED are the most effective procedures for patients with single‐segment LSS. Because of combining efficacy and safety, MTD may be the most promising routine surgical option for treating single‐segment LSS.

Brain Network Changes in Lumbar Disc Herniation Induced Chronic Nerve Roots Compression Syndromes

Lumbar disc herniation (LDH) induced nerve compression syndromes have been a prevalent problem with complex neural mechanisms. Changes in distributed brain areas are involved in the occurrence and persistence of syndromes. The present study aimed to investigate the changes of brain functional network in LDH patients with chronic sciatica using graph theory analysis. A total of thirty LDH adults presenting L4 and/or L5 root (s) compression syndromes (LDH group) and thirty age-, sex-, BMI- and education-matched healthy control (HC group) were recruited for functional MRI scan. Whole-brain functional network was constructed for each participant using Pearson's correlation. Global and nodal properties were calculated and compared between two groups, including small-worldness index, clustering coefficient, characteristic path length, degree centrality (DC), betweenness centrality (BC) and nodal efficiency. Both LDH and HC groups showed small-world architecture in the functional network of brain. However, LDH group showed that nodal centralities (DC, BC and nodal efficiency) increased in opercular part of inferior frontal gyrus; and decreased in orbital part of inferior frontal gyrus, lingual cortex and inferior occipital gyrus. The DC and efficiency in the right inferior occipital gyrus were negatively related with the Oswestry Disability Index in LDH group. In conclusion, the LDH-related chronic sciatica syndromes may induce regional brain alterations involving self-referential, emotional responses and pain regulation functions. But the whole-brain small-world architecture was not significantly disturbed. It may provide new insights into LDH patients with radicular symptoms from new perspectives.

Clinical Evaluation of Paraspinal Mini-Tubular Lumbar Decompression and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spondylolisthesis Grade I with Lumbar Spinal Stenosis: A Cohort Study

Objective

To investigate the clinical outcome data and difference in efficacy between paraspinal mini-tubular lumbar decompression (PMTD) and minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the treatment of degenerative lumbar spondylolisthesis grade I with lumbar spinal stenosis (DLS-I-LSS).

Methods

Patients with DLS-I-LSS, who underwent PMTD or MIS TLIF from September 2017 to March 2020, were included retrospectively. The follow-up period was 24 months after surgery. Outcome measurements included the Oswestry disability index (ODI) score, visual analog scale (VAS) low back pain score, VAS leg pain score, surgical data, and adverse events.

Results

A total of 104 patients with DLS-I-LSS were included in this study. The average improvement in ODI at 12 months (2.0%, 95% CI, −5.7% to 1.8%; p = 0.30) and 24 months (1.7%, 95% CI, −2.7% to 6.1%; p = 0.45) after surgery between the two groups were not statistically significant. The improvement in VAS low back pain score after 24 months and improvement in VAS leg pain score were not significantly different between the two groups. Compared with the PMTD group, the MIS TLIF group had more estimated blood loss and longer hospital stays. The cumulative reoperation rates were 5.66% and 1.96% in the MIS TLIF and PMTD groups, respectively (p = 0.68). The results of multivariate analysis showed that BMI, diabetes, and baseline ODI score were the main factors influencing the improvement in ODI in patients with DLS-I-LSS after minimally invasive surgery, accounting for 50.5% of the total variance.

Conclusions

The clinical effectiveness of PMTD was non-inferior to that of MIS TLIF for DLS-I-LSS; however, there was a reduced duration of hospital stay, operation time, blood loss, and hospitalization costs in the PMTD group. BMI, presence or absence of diabetes and baseline ODI score were influencing factors for the improvement of ODI (Trial Registration: ChiCTR2000040025).

Diagnosis and Management of Lumbar Spinal Stenosis: A Review

IMPORTANCE

Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide. Most are treated nonoperatively. Approximately 600 000 surgical procedures are performed in the US each year for lumbar spinal stenosis.

OBSERVATIONS

The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age. The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI). Nonoperative treatment includes activity modification such as reducing periods of standing or walking, oral medications to diminish pain such as nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. In a series of patients with lumbar spinal stenosis followed up for up to 3 years without operative intervention, approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse. Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated. Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management. For example, in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy (difference, 7.8 points; 95% CI, 0.8-14.9; minimum clinically important difference, 10-12.8) on the Oswestry Disability Index (score range, 0-100). Among persons with lumbar spinal stenosis and concomitant spondylolisthesis, lumbar fusion increased symptom resolution in 1 trial (difference, 5.7 points; 95% CI, 0.1 to 11.3) on the 36-Item Short Form Health Survey physical dimension score (range, 0-100), but 2 other trials showed either no important differences between the 2 therapies or noninferiority of lumbar decompression alone compared with lumbar decompression plus spinal fusion (MCID, 2-4.9 points). In a noninferiority trial, 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score, consistent with the prespecified noninferiority hypothesis. Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear.

CONCLUSIONS AND RELEVANCE

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with continued pain and activity limitation may be candidates for decompressive surgery.

Mid-term changes in spinopelvic sagittal alignment in lumbar spinal stenosis with coexisting degenerative spondylolisthesis or scoliosis after minimally invasive lumbar decompression surgery: minimum five-year follow-up

BACKGROUND CONTEXT

Recently, the number of patients with lumbar spinal stenosis (LSS) who present with a coexisting spinal deformity such as degenerative spondylolisthesis (DS) and scoliosis (DLS) has been increasing. Lumbar decompression without fusion can lead to a reactive improvement in the lumbar and sagittal spinopelvic alignment, even if a sagittal imbalance exists preoperatively. However, the mid- to long-term impact of the coexistence of DS and DLS on the change in sagittal spinopelvic alignment and clinical outcomes after decompression surgery remains unknown.

PURPOSE

This study aimed to investigate whether the coexistence of DS or DLS in patients with LSS is associated with differences in radiological and clinical outcomes after minimally invasive lumbar decompression surgery.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

A total of 169 patients who underwent minimally invasive lumbar decompression surgery and follow-up >5 years postoperatively.

OUTCOME MEASURES

Self-report measures: Low back pain (LBP) and/or leg pain and/or leg numbness visual analog scale (VAS) scores and the Japanese Orthopedic Association scores.

PHYSIOLOGIC MEASURES

Standing sagittal spinopelvic alignment.

METHODS

In total, 81 patients with LSS, 50 patients with LSS and DS (≥3 mm anterior slippage), and 38 patients with LSS and DLS (≥15° coronal Cobb angle) were included in the current study. Clinical and radiological outcome results before surgery and at 2 and 5 years after surgery were compared among the groups.

RESULTS

In patients with LSS with coexisting DS, the clinical outcomes at 2, and 5 years after surgery were similar to those of patients with only LSS. In patients with LSS with coexisting DLS, the VAS LBP and leg pain at 2 years after surgery was significantly higher (34.7 vs. 27.8, p=0.014; 27.8 vs. 14.7, p=0.028) and the achievement rate of the minimal clinically important difference in VAS LBP and leg pain was significantly lower than that of the LSS group (36.1% vs. 54.2%, p=0.036; 58.3% vs. 69.9%, p=0.10). The clinical outcomes except VAS leg numbness at 5 years after surgery were similar to those of patients with only LSS. The reoperation rate of the DS group was significantly lower than that of the LSS group (4.0% vs. 14.8%; p=0.01); however, the reoperation rate of the DLS group was comparable to that of the LSS group (15.8% vs. 14.8%; p=0.493). Lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence-LL had significantly improved and been maintained for 5 years after the surgery in both the DS and the DLS groups. The sagittal vertical axis had improved at two-year follow-up; however, no significant difference was observed at the 5-year follow-up in both the DS, and the DLS groups.

CONCLUSIONS

Mid-term clinical outcomes in patients with LSS with and without deformity were comparable. Lumbar decompression without fusion can result in a reactive improvement in the lumbar and sagittal spinopelvic alignment, even with coexisting DS or DLS. Minimally invasive surgery could be considered for most patients with LSS.

An update of current therapeutic approach for Intervertebral Disc Degeneration: A review article

Intervertebral disc degeneration is a natural process of aging. It can cause physical, psychological, and socioeconomic impact due to the decreasing function of the spine and pain manifestation. Conservative and surgical treatment to correct symptoms and structural anomalies does not fully recover the degenerated disc. Several therapeutic approaches have been developed to improve the clinical result and patient's quality of life. This paper aims to review previous studies that discussed potential novel approach in order to make effective degenerated disc restoration. We tried to briefly describe IVD, IDD, also review several promising current therapeutic approaches for degenerated disc treatment, including its relevance to the degeneration process and limitation to be applied in a clinical setting. There are generally four current therapeutic approaches that we reviewed; growth factors, small molecules, gene therapy, and stem cells. These new approaches aim to not only correct the symptoms but also restore and delay the degeneration process.

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Intervertebral Disc Degeneration.

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Current Therapeutic Approach.

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Stem Cell Therapy.

Effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy

PURPOSE

The effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy was compared.

METHODS

Individuals treated with laminectomy with fusion or laminectomy alone at or below the second cervical vertebra were identified in the Swedish spine registry. 66 individuals treated with laminectomy and instrumented fusion were age matched to 132 individuals treated with laminectomy alone. The European Myelopathy Scale (EMS), the Neck Disability Index (NDI), the Numeric Rating Scale (NRS) for neck pain and the EQ-5D index were available at baseline, and at 1 and 2 year follow-ups. Statistical analyses were performed with Mann-Whitney U tests and paired T tests. Effect sizes were described with Cohen's D.

RESULTS

Data at baseline did not differ significantly between the groups with the exception of a longer laminectomy in the fusion group (4.2 vs 3.4 vertebras; p < 0.001). Both groups improved EMS, NDI, NRS and EQ-5D from baseline to 1 year (p ≤ 0.011), with no additional improvement between 1 and 2 years (all p ≥ 0.09). Effect sizes for change from baseline were small to medium in both groups. At 2 years the laminectomy with fusion group and the laminectomy alone group had a median (25th;75th percentile) EMS of 13 (11;13) and 13 (11;15) (p = 0.77), NDI of 39 (24;54) and 27 (10;41) (p = 0.045), NRS of 4 (1;2) and 2 (0;5) (p = 0.048), and EQ-5D index of 0.67 (0.25;0.73) and 0.66 (0.17;0.76) (p = 0.96).

CONCLUSION

The results of this study suggest similar effectiveness of laminectomy with instrumented fusion and laminectomy alone in degenerative cervical myelopathy.

LEVEL OF EVIDENCE

III.

Comparison of decompression, decompression plus fusion, and decompression plus stabilization: a long-term follow-up of a prospective, randomized study

BACKGROUND CONTEXT

Lumbar canal stenosis due to degenerative lumbar spondylolisthesis is one of the most common indications for lumbar spinal surgery. However, from a long-term perspective, it is still unclear which of these procedures should be performed: decompression, decompression plus fusion, or decompression plus stabilization.

PURPOSE

This study aimed to present the long-term results of a randomized controlled trial of surgery for degenerative spondylolisthesis.

STUDY DESIGN/SETTING

This is a long-term follow-up of a previously reported randomized controlled trial.

PATIENT SAMPLE

Patients aged ≤75 years with single L4/5 level lumbar canal stenosis caused by degenerative lumbar spondylolisthesis were enrolled at two hospitals from May 1, 2003, to April 30, 2012; the final follow-up was on May 20, 2021.

OUTCOME MEASURES

The following data were collected: modified Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score for lower back pain, leg pain, and numbness, and scores from eight Short-Form 36 (SF-36) subscales preoperatively, 1 year postoperatively, 5 years postoperatively, and at the final follow-up.

METHODS

Patients were randomized to undergo decompression alone, decompression plus fusion, or decompression plus stabilization. The primary outcome measure was the change in VAS for lower back pain with secondary outcomes including the modified JOA score, VAS for leg pain, VAS for leg numbness, eight SF-36 subscale scores, and occurrence of reoperation at the last follow-up.

RESULTS

Among 85 patients who were randomized, 66 responded to the current survey. The mean follow-up period was 12.3 years. The VAS score for low back pain improvement was not significantly different between the decompression and fusion groups at the mean follow-up of 12.3 years. Of the 12 secondary outcomes, 8 showed no significant difference between decompression and fusion, 12 showed no significant difference between decompression and stabilization, and 10 showed no significant difference between fusion and stabilization.

CONCLUSIONS

Although additional instrumentation surgery did not significantly improve low back pain at the mean follow-up of 12.3 years compared with decompression alone, fusion surgery provided clinically meaningful improvements in patient-reported vitality, social functioning, role limitations due to personal or emotional problems, and mental health compared with decompression alone.

TRIAL REGISTRATION

UMIN000028114.

Neurosurgical Study Design: Past and Future

Clinical trials are performed to determine the safety, efficacy, or effectiveness of a medical or surgical intervention. A clinical trial is, by definition, prospective in nature with a uniform treatment of a defined patient cohort. The outcomes assessment should also be uniform. Often a control group is included. At present, the number of neurosurgical clinical trials is increasing, and the study designs have become more sophisticated. Historically, the standard of neurosurgical care has evolved from the findings from many case series and retrospective comparative studies. However, in the present report, we have focused exclusively on prospective clinical trials. An urgent need exists to understand how clinical trials have been performed in the past and how they can be improved to advance our neurosurgical practice. In the present review, we have discussed the barriers, successes, and failures regarding prospective clinical trials in neurosurgery with an outlook to the future.

The duration of chronic low back pain is associated with acute postoperative pain intensity in lumbar fusion surgery: a prospective observational study

BACKGROUND

Pre-existing chronic pain has been associated with severe postoperative pain. In this study, we sought to prospectively analyse the association between the duration of chronic low back pain and the intensity of acute postoperative pain after lumbar fusion surgery.

METHODS

A total of 330 patients who underwent lumbar fusion surgery were divided into three groups (chronic low back pain less than 1 year, one to 5 years, and more than 5 years) based on the duration of chronic pain. On the first postoperative day, the maximum pain scores of each patient were recorded during the day and at night. Bivariate correlation and logistic regression were performed to identify relationships between acute postoperative pain and related variables (age, sex, smoking history, body mass index, operation history, duration of surgery, level of preoperative pain, aetiology of back pain, Self-rating Anxiety Scale, Self-rating Depression Scale, FRAIL scale, and duration of chronic low back pain). If the postoperative pain score was > 3 when the patient reported was at rest, the patients were treated with postoperative intravenous self-controlled analgesia or rescue analgesics if necessary.

RESULTS

There was an association between severe acute postoperative pain and the duration of chronic low back pain. In terms of VAS day, multivariable logistic regression showed the duration of chronic low back pain was not statistically significant (OR = 2.48, 95% CI: 0.900 to 6.828, p = 0.0789). The result is uncertain because the confidence interval included the null after controlling for SAS, SDS, BMI, and aetiology of back pain. In terms of VAS night, patients with a duration of chronic low back pain of more than 5 years were more likely having moderate to severe acute postoperative pain (VAS > 3) compared to patients with a duration of chronic low back pain less than 1 year (OR = 3.546, 95% CI: 1.405 to 8.95, p = 0.0074). Hospital stay, the pain score on the day of discharge and the pain score after 3 months displayed no significant difference among the three groups (P > 0.05). However, the need for postoperative rescue analgesics was different among the three groups (P < 0.05).

CONCLUSION

The longer the duration of chronic pain was, the higher the incidence of moderate to severe acute postoperative pain was and the greater the amount of analgesics required after surgery.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trial Registration Center ( http://www.chictr.org.cn/index.aspx , clinical trial number: ChiECRCT20200165, date of registration: July 6, 2020).

The Learning Curve of Unilateral Biportal Endoscopic (UBE) Spinal Surgery by CUSUM Analysis

Objective

To assess the learning curve of the unilateral biportal endoscopic (UBE) technique for the treatment of single-level lumbar disc herniation by cumulative summation (CUSUM) method analysis.

Methods

A retrospective analysis was conducted to assess 97 patients' general condition, operation time, complications, and curative effect of single segmental UBE surgery performed by a spinal surgeon in his early stage of this technique. The learning curve of operation time was studied using a CUSUM method, and the cut-off point of the learning curve was obtained.

Results

The operation time was 30 – 241(97.9 ± 34.7) min. The visual analog scale score of lower limb pain decreased from 5.75 ± 0.81 before the operation to 0.39 ± 0.28 at the last follow-up (P &lt; 0.05). The Oswestry disability index score decreased from 66.48 ± 4.43 before the operation to 14.57 ± 3.99 at the last follow-up (P &lt; 0.05). The CUSUM assessment of operation time revealed the learning curve was the highest in 24 cases. In the learning stage (1–24 cases), the operation time was 120.3 ± 43.8 min. In the skilled stage (25–97 cases), the operation time was 90.5 ± 27.8 min.

Conclusions

About 24 cases of single segmental UBE operation are needed to master the UBE technique.

Accuracy and quality of the British Orthopaedic Foot and Ankle Society (BOFAS) Registry - Ankle Arthrodesis Pathway

BACKGROUND

This study investigated the completeness, accuracy, quality and clinical outcomes of the British Orthopaedic Foot and Ankle Society (BOFAS) registry - Ankle Arthrodesis pathway.

METHODS

An observational study using retrospective data derived from the BOFAS registry. Adults aged ≥18 years with a record of undergoing ankle arthrodesis in the UK from 2014 to 31/10/2019 were included. Accuracy of data capture and completeness were explored using means, SD, medians and IQR for continuous variables and frequencies for categorical variables. The pre and post treatment pathway was evaluated by analysing Patient Reported Outcome Measures (PROMs) including MOXF-FQ scores for pain/walking/standing/social interaction; NRS pain; EQ-5D-5L; and EQ-5D-5L-Health VAS at baseline, 6 months, and 12 months.

RESULTS

Mean age of the study population (n = 186) was 62.3 (±12.9) years and 65% of the study cohort were male. Completeness of data collection was disappointing but variables such as BMI (62.4%) smoking status (82.3%) were reasonably well recorded. PROMs scores were well recorded at baseline but rapidly declined at 6 and 12-months intervals. Reductions in MOXFQ and NRS pain scores by 12 months following surgery were statistically significant (p = 0.001 and p = 0.008), illustrating that most patients demonstrated reductions in pain intensity, improved walking/standing ability, and social interaction.

CONCLUSION

These findings illustrate the potential effectiveness of surgery on all outcomes following ankle arthrodesis that merits evaluation in a clinical trial; but also demonstrated the difficulties in obtaining representative data sets. The analyses strongly suggest that with the improvements in data quality greater resources would bring, the BOFAS registry would become a valuable tool.

Reoperations After Decompression With or Without Fusion for L3-4 Spinal Stenosis With Degenerative Spondylolisthesis: A Study of 372 Patients in Swespine, the National Swedish Spine Register

STUDY DESIGN

Register study with prospectively collected data.

OBJECTIVE

The aim was to investigate reoperation rates at the index level and the adjacent levels after surgery for lumbar L3-4 spinal stenosis with concomitant degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA

There are different opinions on how to surgically address lumbar spinal stenosis with DS. The potential benefit of fusion surgery should be weighed against the risks of future reoperations because of adjacent segment degeneration. Data on the reoperation rate at adjacent segments after single level L3-4 fusion surgery are limited.

MATERIALS AND METHODS

A total of 372 patients, who underwent surgery for lumbar L3-4 spinal stenosis with DS (slip >3 mm) between 2007 and 2012, were followed between 2007 and 2017 to identify reoperations at the index level and adjacent levels. The reoperation rate for decompression and fusion was compared with the reoperation rate for decompression only. Patient-reported outcome measures before and 1 year after surgery were evaluated.

RESULTS

The reoperation rate at the index level (L3-4) was 3.5% for decompression and fusion and 5.6% for decompression only. At the cranial adjacent level (L2-3), the corresponding numbers were 6.6% and 4.2%, respectively, and the caudal adjacent level (L4-5), the corresponding numbers were 3.1% and 4.9%, respectively. The effect sizes of change were larger for decompression and fusion compared with decompression only. The effect sizes of change were similar for leg pain and back pain.

CONCLUSIONS

We could not identify any differences in reoperation rates at the cranial or caudal adjacent segment after decompression and fusion compared with decompression only for L3-4 spinal stenosis with DS. The improvement in back pain is similar to the improvement in leg pain after surgery for L3-4 spinal stenosis with DS.

Responsiveness and Minimal Clinically Important Difference of the 6-minute Walk Distance in Patients Undergoing Lumbar Spinal Canal Stenosis Surgery

STUDY DESIGN

This was a retrospective review of prospectively collected data.

OBJECTIVE

We aimed to evaluate the responsiveness of the 6-minute walk distance (6MWD) and determine the threshold of the minimal clinically important difference (MCID) in the 6MWD in patients who underwent surgery for lumbar spinal canal stenosis (LSS) surgery.

SUMMARY OF BACKGROUND DATA

The 6MWD rapidly and objectively assesses the walking distance in patients with LSS. To date, no study has assessed the MCID in the 6MWD in patients who underwent LSS surgery.

MATERIALS AND METHODS

A total of 41 patients (16 women; average age: 69.4 y, SD: 7.8 y) were included and assessed preoperatively and at 6 months postoperatively. We evaluated the 6MWD and Oswestry Disability Index (ODI), which is a health-related patientrReported outcome, used as an anchor to calculate the MCID for in the 6MWD. We used 2 different approaches to examine the responsiveness of the 6MWD: internal and external responsiveness. The external responsiveness was assessed in 2 ways: one based on the anchoring questionnaire and the other based on the scale distribution of the scale. The anchor-based approach was evaluated using the Spearman rank correlation coefficient and the receiver operating characteristic curve. The distribution-based approach was evaluated using the minimal detectable change.

RESULTS

The ODI scores and 6MWD for each anchor significantly improved postoperatively. The correlation coefficient between changes in the 6MWD and ODI was r=-0.58. The area under the receiver operating characteristic curve for the ODI anchor was 0.70 (95% confidence interval: 0.52-0.89), and the cutoff value for the ODI anchor was 50 m (sensitivity=0.57, specificity=0.71). In the distribution-based approach, the minimal detectable change for the 6MWD was 105.9 m.

CONCLUSIONS

Both the internal and the external responsiveness of the 6MWD were validated using the ODI. Therefore, the MCID in the 6MWD in patients undergoing LSS surgery ranges from 50 to 105.9 m.

LEVEL OF EVIDENCE

Level III.

No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis: Results From the National Swedish Spine Registry 2-Year Post-Op

STUDY DESIGN

Observational cohort study.

OBJECTIVE

The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear.

METHODS

All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery.

RESULTS

Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64).

CONCLUSION

In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.Level of Evidence: 3.

How Decompression Surgery Improves the Lower Back Pain in Patient with Lumbar Degenerative Stenosis: A Propensity-score-matched Analysis

STUDY DESIGN

Multicenter retrospective case series of patients treated surgically for lumbar spinal stenosis (LSS).

OBJECTIVE

We investigated how laminectomy improves lower back pain (LBP) and the factors associated with poor improvement.

SUMMARY OF BACKGROUND DATA

Lumbar laminectomy is effective for alleviating neurological symptoms caused by LSS, whereas its effect on LBP is still controversial.

METHODS

A retrospective review of prospectively collected data from 436 patients (age 72 yrs, 69% males) who underwent laminectomy for LSS with 2 years of follow-up. We analyzed the following risk factors for residual LBP by uni- and multivariate analyses: age, sex, smoking, occupation, comorbidities, frailty, joint replacement, vertebral fracture, DISH, HRQOL, complications, and the presence of spinal instability. The LBP of male and female patients was analyzed after propensity score matching of known confounders. Patient-reported outcomes (JOABPEQ and VAS scores) were obtained at baseline and the 2-year postoperative follow-up.

RESULTS

LBP was significantly improved at 2 years post operation (VAS change 2.3 [95% CI 2.0-2.6], P < 0.01). Fifty-five percent of the patients achieved an MCID, with 67% having no or mild LBP. In the multivariate analysis, sex and baseline LBP were independent risk factors (female: OR 1.9 [1.2-3.0], baseline LBP [VAS≥7.5]: OR 1.9 [1.2-3.1]). Furthermore, the independent risk factors for severe baseline LBP were sex and mental status (female: OR 1.7 [1.1-2.7], P = 0.03, mental status: OR 3.8 [2.4-6.0], P < 0.01). However, an analysis of 102 pairs of propensity-score-matched male and female patients showed no difference in the improvement of LBP (male vs. female: VAS 3.8 ± 2.8 vs. 4.0 ± 2.9, P = 0.61, VAS change 3.1 ± 2.9 vs. 2.7 ± 3.0, P = 0.38).

CONCLUSION

Decompression surgery for LSS significantly improved LBP. Sex and baseline LBP were risk factors for residual LBP. However, when males and females were matched by confounders, no difference was found in the LBP after surgery. Patients with severe baseline LBP may need further evaluation for their mental status because these patients are likely to have mental problems that potentially contribute to persistent LBP.Level of Evidence: 4.

The 100 Most Cited Articles on Lumbar Spinal Stenosis: A Bibliometric Analysis

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

With the increasing literature of spine surgery, some pioneering research studies have had a significant impact on the field of lumbar spinal stenosis (LSS). The objective of the authors was to identify and analyze the most frequently cited 100 articles in this field.

METHODS

Web of Science was searched to identify 100 top-cited articles related to LSS from 2000 to 2019. Articles on the final list were filtered based on their titles and abstracts. The following information were recorded and analyzed with bibliometric method: article title, first author, year of publication, journal of publication, total number of citations, country, institution, and study topic.

RESULTS

The citation count for final articles on the list ranged from 71 to 2162, with a mean number of 207.7. The journal Spine contributed the maximum number of articles (37), followed by European Spine Journal (9) and Pain Physician (8). There were collectively 80 first authors contributing to articles on the final list. Twelve authors were represented multiple times in the top 100 articles. The most prolific years were 2008 and 2009, each had 11 articles published. With regard to country and region of origin, most articles were from the United States (58). The most cited article was published in Spine in 2000 by Fairbank and Pynsent, who discussed the role of the Oswestry Disability Index as an evaluation standard in spinal disorders, including LSS.

CONCLUSION

The current study analyzed the 100 most cited articles on LSS. It no doubt developed a useful resource with detailed information for many, particularly orthopedic and neurosurgery physicians who want to assimilate research focus and advance of LSS within a relatively short period. Researchers may benefit from emphasis on citation count while citing and evaluating articles and realize the deficiencies when high-level articles appear.

Second opinions for spinal surgery: a scoping review

BACKGROUND

Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.

METHODS

We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.

RESULTS

We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).

CONCLUSIONS

Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

Lumbar Spinal Stenosis with Degenerative Spondylolisthesis Treated with Decompression Alone. A Cohort of 346 Patients at a Large Spine Unit. Clinical Outcome, Complications and Subsequent Surgery

STUDY DESIGN

Cohort study.

OBJECTIVE

To study the clinical outcome, complications and subsequent surgery rate of DA for lumbar spinal stenosis (LSS) with DS.

SUMMARY OF BACKGROUND DATA

There is still no consensus regarding the treatment approach for LSS with DS.

METHODS

We performed a retrospectively designed cohort study on prospectively collected data from a single high productive spine surgical center. Results from the Swedish Spine Registry and a local register for complications were used for the analyses. Patients with LSS and DS (>3 mm) who underwent DA during January 2012 to August 2017 were included. Patient reported outcome measures at baseline and 2 years after surgery were analyzed. Complications within 30 days of surgery and all subsequent surgery in the lumbar spine were registered.

RESULTS

We identified and included 346 patients with completed 2-year follow-up registration. At 2-year follow-up there was a significant improvement in all outcome measures. The global assessment success rate for back and leg pain was 68.3% and 67.6% respectively. Forty-one patients had at least 1 intra- or postoperative complication (11.9%). Nine patients (2.6%), underwent subsequent surgery within 2 years of the primary surgery whereof 2 underwent fusion. During the whole period of data collection, that is, as of June 2020, 28 patients had undergone subsequent surgery (8.1%) whereas 8 of them had had 2 surgeries. Fifteen patients underwent fusion.

CONCLUSION

DA provides good clinical outcome at 2-year follow-up in patients with LSS and DS with low rate of intra- and postoperative complications and subsequent surgery. Our data supports the evidence that DA is effective and safe for LSS with DS.Level of Evidence: 3.

The clinical effectiveness of a physiotherapy delivered physical and psychological group intervention for older adults with neurogenic claudication: the BOOST randomised controlled trial

Background

Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults’ mobility and quality of life.

Methods

A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat.

Results

The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: −1.4 [95% confidence intervals (CI) −4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: −3.7 [95% CI −6.27, −1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment.

Conclusions

The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability.

Clinical Trials Registration Number: ISRCTN12698674

Evaluation of the Predictors for Unfavorable Clinical Outcomes of Degenerative Lumbar Spondylolisthesis After Lumbar Interbody Fusion Using Machine Learning

Background

An increasing number of geriatric patients are suffering from degenerative lumbar spondylolisthesis (DLS) and need a lumbar interbody fusion (LIF) operation to alleviate the symptoms. Our study was performed aiming to determine the predictors that contributed to unfavorable clinical efficacy among patients with DLS after LIF according to the support vector machine (SVM) algorithm.

Methods

A total of 157 patients with single-segment DLS were recruited and performed LIF in our hospital from January 1, 2015 to October 1, 2020. Postoperative functional evaluation, including ODI and VAS were, performed, and endpoint events were defined as significant relief of symptom in the short term (2 weeks postoperatively) and long term (1 year postoperatively). General patient information and radiological data were selected and analyzed for statistical relationships with the endpoint events. The SVM method was used to establish the predictive model.

Results

Among the 157 consecutive patients, a postoperative unfavorable clinical outcome was reported in 26 patients (16.6%) for a short-term cohort and nine patients (5.7%) for a long-term cohort. Based on univariate and multivariate regression analysis, increased disc height (DH), enlarged facet angle (FA), and raised lateral listhesis (LLS) grade were confirmed as the risk factors that hindered patients' short-term functional recovery. Furthermore, long-term functional recovery was significantly associated with DH alone. In combination with the SVM method, a prediction model with consistent and superior predictive performance was achieved with average and maximum areas under the receiver operating characteristic curve (AUC) of 0.88 and 0.96 in the short-term cohort, and 0.78 and 0.82 in the long-term cohort. The classification results of the discriminant analysis were demonstrated by the confusion matrix.

Conclusions

The proposed SVM model indicated that DH, FA, and LLS were statistically associated with a clinical outcome of DLS. These results may provide optimized clinical strategy for treatment of DLS.

Surgical management of lumbar spinal stenosis in patients over 80: is there an increased risk?

Management of lumbar spinal stenosis (LSS) represents the first cause of spinal surgery for the elderly and will increase with the aging population. Although the surgery improves quality of life, the procedure involves anaesthetic and operative risks. The aim of this study was to assess whether the postoperative complication rate was higher for elderly patients and to find confounding factors. We conducted a retrospective study including all LSS surgeries between 2012 and 2020 at the University Hospital of Caen. We compared two populations opposing patients aged over 80 with others. The primary endpoint was the occurrence of a severe complication (SC). Minor complications were the secondary endpoint. Comorbidities, history of lumbar spine surgery and surgical characteristics were recorded. Nine hundred ninety-six patients undergoing surgery for degenerative LSS were identified. Patients over 80 were significantly affected by additional comorbidities: hypertension, heart diseases, higher age-adjusted comorbidity Charlson score, ASA score and use of anticoagulants. Knee-chest position was preferred for younger patients. Older patients underwent a more extensive decompression and had more incidental durotomies. Of the patients, 5.2% presented SC. Age over 80 did not appear to be a significant risk factor for SC, but minor complications increased. Multivariate analysis showed that heart diseases, history of laminectomy, AA-CCI and accidental durotomies were independent risk factors for SC. Surgical management for lumbar spinal stenosis is not associated to a higher rate of severe complications for patients over 80 years of age. However, preoperative risk factors should be investigated to warn the elderly patients that the complication risk is increased although an optimal preparation is the way to avoid them.

Facet Joint Opening on Computed Tomography Is a Predictor of Poor Clinical Outcomes After Minimally Invasive Decompression Surgery for Lumbar Spinal Stenosis

STUDY DESIGN

Retrospective longitudinal cohort study.

OBJECTIVE

To investigate the impact of facet joint opening (FJO) on clinical outcomes after minimally invasive decompression surgery for lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

Although FJOs have previously been identified as indicators of segmental spinal instability, their impact on clinical outcomes after decompression alone surgery has yet to be investigated.

METHODS

This study included 296 patients from a single institution who underwent minimally invasive surgery for lumbar spinal stenosis and were followed up for ≥5 years. Our analysis focused on identifying FJOs at the index decompression level (d-FJO) and at multiple levels (m-FJO) (i.e., ≥3 levels within the lumbar segment) using preoperative computed tomography. Clinical outcomes including reoperations, improvement ratio for Japanese Orthopaedic Association score, and achievement of a minimal clinically important difference in visual analogue scale scores for low back pain or leg pain at 5 years were compared between patients with and without d-FJO or m-FJO.

RESULTS

There were 129 (44%) and 62 (21%) patients with d-FJO (more common with lateral olisthesis) and m-FJO (less common with spondylolisthesis), respectively. Reoperations were more common in patients with d-FJO than in those without (16% vs. 5%). On Cox proportional hazards analysis, d-FJO was identified as a predictor for revision at the index decompression level (hazard ratio 4.04, P = 0.03), whereas m-FJO was a predictor for revision at other lumbar levels (hazard ratio 3.71, P = 0.03). Patients with m-FJO had slightly lower rates of achieving minimal clinically important difference in visual analogue scale scores for low back pain (34% vs. 52%, P = 0.03) and poorer improvement ratio for Japanese Orthopaedic Association scores (74% vs. 80%, P = 0.03) than those without.

CONCLUSION

FJO at both index decompression level and multiple level were predictors of poor outcomes; patients with FJOs require careful surgical planning or special follow-up.Level of Evidence: 3.

Quantitative Gait Analysis of Patients with Severe Symptomatic Spinal Stenosis Utilizing the Gait Profile Score: An Observational Clinical Study

Lumbar spine stenosis (LSS) typically manifests with neurogenic claudication, altering patients’ gait. The use of optoelectronic systems has allowed clinicians to perform 3D quantitative gait analysis to quantify and understand these alterations. Although several authors have presented analysis of spatiotemporal gait parameters, data concerning kinematic parameters is lacking. Fifteen patients with LSS were matched with 15 healthy controls. Quantitative gait analysis utilizing optoelectronic techniques was performed for each pair of subjects in a specialized laboratory. Statistical comparison of patients and controls was performed to determine differences in spatiotemporal parameters and the Gait Profile Score (GPS). Statistically significant differences were found between patient and control groups for all spatiotemporal parameters. Patients had significantly different overall GPS (p = 0.004) and had limited internal/external pelvic rotation (p < 0.001) and cranial/caudal movement (p = 0.034), limited hip extension (p = 0.012) and abduction/adduction (p = 0.012) and limited ankle plantar flexion (p < 0.001). In conclusion, patients with LSS have significantly altered gait patterns in three regions (pelvis, hip and ankle) compared to healthy controls. Analysis of kinematic graphs has given insight into gait pathophysiology of patients with LSS and the use of GPS will allow us to quantify surgical results in the future.

External Validation of the Minimum Clinically Important Difference in the Timed-up-and-go Test After Surgery for Lumbar Degenerative Disc Disease

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVE

The aim of this study was to provide external validation of the minimum clinically important difference (MCID) of the Timed-up-and-go (TUG) test.

SUMMARY OF BACKGROUND DATA

The TUG test is one of the best explored and most frequently applied objective task-based functional outcome measure in patients with lumbar degenerative disc disease (DDD). The increased use of the TUG test is based on its solid psychometric properties; however, an external validation of the originally determined MCID is lacking.

METHODS

Forty-nine patients with lumbar DDD, scheduled for elective spine surgery, were assessed pre- and 6-weeks (W6) postoperative. MCID values were calculate for raw TUG test times (seconds) and standardized TUG z scores using three different computation methods and the following established patient-reported outcome measures (PROMs) as anchors: Visual Analog Scales (VAS), Core Outcome Measures Index Back, Zurich Claudication Questionnaire (ZCQ).

RESULTS

The three computation methods generated a range of MCID values, depending on the PROM used as anchor, from 0.9 s (z score of 0.3) based on the VAS leg pain to 3.0 seconds (z score of 2.7) based on the ZCQ physical function scale. The average MCID of the TUG test across all anchors and computation methods was 2.1 s (z score of 1.5). According to the average MCID of raw TUG test values or TUG z scores, 41% and 43% of patients classified as W6 responders to surgery, respectively.

CONCLUSION

This study confirms the ordinally reported TUG MCID values in patients undergoing surgery for lumbar. A TUG test time change of 2.1 seconds (or TUG z score change of 1.5) indicates an objective and clinically meaningful change in functional status. This report facilitates the interpretation of TUG test results in clinical routine as well as in research.Level of Evidence: 3.

Decompression Alone Compared to Decompression With Fusion in Patients With Lumbar Spondylolisthesis: Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

We aimed to synthesize the latest evidence on the efficacy and safety of decompression alone compared to decompression with fusion in patients with lumbar spondylolisthesis. We also aimed to evaluate factors affecting the efficacy and complications.

METHODS

A systematic literature search was conducted using PubMed, Scopus, Europe PMC, Cochrane Central Database, and ClinicalTrials.gov. The main outcome was improvement in Oswestry Disability Index (ODI). The secondary outcome was back pain and leg pain improvement, complications, reoperation rate, duration of surgery, length of hospital stay, and blood loss.

RESULTS

There were 3993 patients from 13 studies. Decompression with fusion was associated with greater reduction in ODI (mean difference 4.04 [95% CI 0.95, 7.13], P = 0.01) compared to decompression alone. Greater reduction in back (standardized mean difference [SMD] 0.27 [95% CI 0.00, 0.53], P = 0.05) and leg pain (SMD 0.13 [95% CI 0.06, 0.21], P < 0.001) was observed in the decompression with fusion group. Complications were similar in the 2 groups (OR 0.60 [95% CI 0.34, 1.04], P = 0.07). The reoperation rate was similar in both groups (P = 0.54). Decompression alone resulted in shorter duration of surgery (mean difference -85.18 minutes [95% CI -122.79, -47.57], P < 0.001), less blood loss (mean difference -262.65 mL [95% CI -313.45, -211.85], P < 0.001), and shorter hospital stay (mean difference -2.64 days [95% CI -3.58, -1.70], P < 0.001). Empirical Bayes random-effects meta-regression showed that the rate of complication was influenced by age (coefficient 0.172, P = 0.004).

CONCLUSION

Decompression with fusion had greater efficacy than decompression alone but was associated with more blood loss, lengthier surgery, and hospitalization. In terms of complications, decompression alone may be beneficial in younger patients. (PROSPERO CRD42020211904) LEVEL OF EVIDENCE: 2A.

Global Trends of Researches on Lumbar Spinal Stenosis: A Bibliometric and Visualization Study

STUDY DESIGN

Bibliometric and visualization analysis.

OBJECTIVE

Lumbar spinal stenosis (LSS) has become a common health problem and the most frequent indication for spinal surgery. This study aimed to illustrate the overall knowledge structure, and development trends of LSS, using a bibliometric analysis and newly developed visualization tools.

MATERIALS AND METHODS

Research data sets were acquired from the Web of Science. The time span was defined as "2000-2019". VOS viewer and Citespace software was provided to analyze the data and generate visualization knowledge maps. Annual trend of publications, distribution, H-index status, co-authorship status and research hotspots were analyzed.

RESULTS

A total of 1934 publications met the requirement. The United States published most papers (521, 26.9%), both total citations (17,626) and H-index (61) ranked first of all the countries. The most productive organizations on LSS is Seoul National University (50). Spine (43) published the most papers on LSS. Quality of life, risk factor, disability, double blind trials, and decompression surgery are the research hotspots in the recent years.

CONCLUSION

The number of publications showed an upward trend with a stable rise in recent years. The United States is a country with the highest productivity, not only in quality, but also in quantity. Seoul National University has been the largest contributor in this field. Spine is the best journal related to LSS. Quality of life, risk factor, disability, and decompression surgery are the research hotspots in the recent years. Indeed, this study provides a new insight to the growth and development of LSS. Moreover, it will contribute to the growth of the international frontier of LSS.

Does reduction of the Meyerding grade correlate with outcomes in patients undergoing decompression and fusion for grade I degenerative lumbar spondylolisthesis?

OBJECTIVE

Reduction of Meyerding grade is often performed during fusion for spondylolisthesis. Although radiographic appearance may improve, correlation with patient-reported outcomes (PROs) is rarely reported. In this study, the authors' aim was to assess the impact of spondylolisthesis reduction on 24-month PRO measures after decompression and fusion surgery for Meyerding grade I degenerative lumbar spondylolisthesis.

METHODS

The Quality Outcomes Database (QOD) was queried for patients undergoing posterior lumbar fusion for spondylolisthesis with a minimum 24-month follow-up, and quantitative correlation between Meyerding slippage reduction and PROs was performed. Baseline and 24-month PROs, including the Oswestry Disability Index (ODI), EQ-5D, Numeric Rating Scale (NRS)-back pain (NRS-BP), NRS-leg pain (NRS-LP), and satisfaction (North American Spine Society patient satisfaction questionnaire) scores were noted. Multivariable regression models were fitted for 24-month PROs and complications after adjusting for an array of preoperative and surgical variables. Data were analyzed for magnitude of slippage reduction and correlated with PROs. Patients were divided into two groups: < 3 mm reduction and ≥ 3 mm reduction.

RESULTS

Of 608 patients from 12 participating sites, 206 patients with complete data were identified in the QOD and included in this study. Baseline patient demographics, comorbidities, and clinical characteristics were similarly distributed between the cohorts except for depression, listhesis magnitude, and the proportion with dynamic listhesis (which were accounted for in the multivariable analysis). One hundred four (50.5%) patients underwent lumbar decompression and fusion with slippage reduction ≥ 3 mm (mean 5.19, range 3 to 11), and 102 (49.5%) patients underwent lumbar decompression and fusion with slippage reduction < 3 mm (mean 0.41, range 2 to -2). Patients in both groups (slippage reduction ≥ 3 mm, and slippage reduction < 3 mm) reported significant improvement in all primary patient reported outcomes (all p < 0.001). There was no significant difference with regard to the PROs between patients with or without intraoperative reduction of listhesis on univariate and multivariable analyses (ODI, EQ-5D, NRS-BP, NRS-LP, or satisfaction). There was no significant difference in complications between cohorts.

CONCLUSIONS

Significant improvement was found in terms of all PROs in patients undergoing decompression and fusion for lumbar spondylolisthesis. There was no correlation with clinical outcomes and magnitude of Meyerding slippage reduction.

Artificial Intelligence Algorithm-Based Lumbar and Spinal MRI for Evaluation of Efficacy of Chinkuei Shin Chewan Decoction on Lumbar Spinal Stenosis

The study aimed to explore the application value of lumbar Magnetic Resonance Imaging (MRI) images processed by artificial intelligence algorithms in evaluating the efficacy of chinkuei shin chewan decoction (a traditional Chinese medicine to nourish the kidney) in the treatment of lumbar spinal stenosis (LSS). Specifically, 110 LSS patients admitted to the hospital were selected as the research subjects. They were randomly divided into the control group (n = 55) and experimental group (n = 55) according to different treatment methods. The control group was treated with traditional medicine, and the experimental group additionally took chinkuei shin chewan decoction on its basis. Based on the traditional U-net algorithm, a U-net registration algorithm based on artificial intelligence was designed by introducing the information entropy theory, and the algorithm was applied to the lumbar MRI image evaluation of LSS patients. Compared with the traditional U-net algorithm, the artificial intelligence-based U-net registration algorithm had a decreased noise level (P < 0.05), the Jaccard (J) value (0.84) and the Dice value (0.93) increased significantly versus the traditional algorithm (J = 0.63, Dice = 0.81), and the characteristics of the image were more accurate. Before treatment, the Oswestry Disability Index (ODI) scores of the experimental group and the control group were 44.32 ± 6.45 and 43.32 ± 5.45, respectively. After treatment, the ODI scores of the two groups were 10.21 ± 5.05 and 17.09 ± 5.23, respectively. Both showed significant improvement, while the improvement of the experimental group was more obvious than that of the control group (P < 0.05). The overall effective rates of the two groups of patients were 96.44% and 82.47%, respectively, and the experimental group was significantly higher than the control group (P < 0.05). Under the U-net registration algorithm based on artificial intelligence, the diagnostic accuracy of lumbar MRI in the experimental group was 94.45%, significantly higher than 67.5% before the introduction of the algorithm (P < 0.05). In conclusion, chinkuei shin chewan decoction are effective for the treatment of LSS, and lumbar MRI based on the artificial intelligence U-net registration algorithm can evaluate the efficacy of LSS well and is worthy of promotion.

Treatment of restenosis after lumbar decompression surgery: decompression versus decompression and fusion

OBJECTIVE

The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery.

METHODS

For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher's exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance.

RESULTS

Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar.

CONCLUSIONS

Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

Uniportal Full-Endoscopic versus Minimally Invasive Decompression for Lumbar Spinal Stenosis: A Meta-analysis

BACKGROUND

 In this study, we systematically analyze the effectiveness of the uniportal full-endoscopic (UPFE) and minimally invasive (MIS) decompression for treatment of lumbar spinal stenosis patients.

METHODS

 We performed a systematic search in Medline, Embase, Europe PMC, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, China national knowledge infrastructure, and Wanfang Data databases for all relevant studies. All statistical analyses were performed using Review Manager version 5.3.

RESULTS

 A total of 9 articles with 522 patients in the UPFE group and 367 patients in the MIS group were included. The results of the meta-analysis showed that the UPFE group had significantly better results in hospital stay time (mean difference [MD]: -2.05; 95% confidence interval [CI]: -2.87 to -1.23), intraoperative blood loss (MD: -36.56; 95% CI: -54.57 to -18.56), and wound-related complications (MD: -36.56; 95%CI: -54.57 to -18.56) compared with the MIS group, whereas the postoperative clinical scores (MD: -0.66; 95%CI: -1.79 to 0.47; MD: -0.75; 95%CI: -1.86 to 0.36; and MD: -4.58; 95%CI: -16.80 to 7.63), satisfaction rate (odds ratio [OR] = 1.24; 95%CI: 0.70-2.20), operation time (MD: 30.31; 95%CI: -12.55 to 73.18), complication rates for dural injury (OR = 0.60; 95%CI: 0.29-1.26), epidural hematoma (OR = 0.60; 95%CI: 0.29-1.26), and postoperative transient dysesthesia and weakness (OR = 0.73; 95%CI: 0.36-1.51) showed no significant differences between the two groups.

CONCLUSIONS

 The UPFE decompression is associated with shorter hospital stay time and lower intraoperative blood loss and wound-related complications compared with MIS decompression for treatment of lumbar spinal stenosis patients. The postoperative clinical scores, satisfaction rate, operation time, complication rates for dural injury, epidural hematoma, and postoperative transient dysesthesia and weakness did not differ significantly between two groups.

Endoscopic modified total laminoplasty for symptomatic lumbar spinal stenosis

Context/objective: At present, there is no consensus on the most effective surgical method for treating symptomatic lumbar spinal stenosis (LSS). Total laminectomy, which is frequently used at this time, destroys the posterior midline structure, causing many postoperative complications. We have designed a new surgical approach instead of total laminectomy. In this paper, we aimed to describe the surgical method of endoscopic modified total laminectomy for lumbar spinal stenosis as well as to explore its early efficacy.Participants: Patients with symptomatic LSS who underwent endoscopic modified total laminoplasty between August 2016 and August 2017 were eligible for our study.Outcome measures: Before surgery and one year after surgery, we measured lower limb pain and back pain by visual analog scale (VAS), disability via Oswestry Disability Index (ODI), and severity of back pain according to the Japanese Orthopedic Association Score for Back Pain (JOA), while any complications were also assessed.Results: Endoscopic modified total laminoplasty was performed on 22 LSS patients, including eight males and 14 females(mean age = 59.3 ± 9.6 years). We found statistically significant differences before and one year after surgery for VAS lower limb pain and back pain, ODI and JOA scores(P < 0.001). Complications included intraoperative dural tears(n = 1),and weak fusion between the lamina and the vertebral body (n = 1).Conclusion: Endoscopic modified total laminectomy is a promising surgical approach which reduces patient suffering and improves patient quality of life.

Minimally invasive microsurgical decompression in patients with monosegmental lumbar spinal stenosis

Surgical treatment of degenerative lumbar spinal stenosis is an actual problem of modern spinal surgery and orthopedics.

OBJECTIVE

To analyze the results of minimally invasive microsurgical decompression (MI-MD) in patients with monosegmental lumbar spinal stenosis.

MATERIAL AND METHODS

A retrospective observational cohort study was performed. We analyzed medical records of patients who underwent MI-MD for monosegmental degenerative lumbar spinal stenosis. Clinical and objective results of MI-MD, as well as the types and prevalence of adverse clinical events were studied.

RESULTS

The study included 96 medical records (50 (52%) males and 46 (48%) females aged 18-84 years). Analysis of pain in lower back and lower extremities in 3, 6, 9, 12 and 24 months after MI-MD showed a significant decrease of this indicator (p<0.001). There was significant improvement of capacity according to ODI score up to 5-12% in 72.9% of patients in early postoperative period (p=0.055). In delayed postoperative period, we also observed significant improvement of working capacity according to ODI score and gradual decrease in disability index (p<0.001). Adverse clinical events occurred in 6 (6.2%) patients.

CONCLUSION

MI-MD is a highly effective surgical method for monosegmental lumbar spinal stenosis with minimal incidence of adverse clinical events.

Changes in kinematics, kinetics, and muscle activity in patients with lumbar spinal stenosis during gait: systematic review

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) is one of the most common orthopaedic conditions and affects more than half a million people over the age of 65 in the US. Patients with LSS have gait dysfunction and movement deficits due to pain and symptoms caused by compression of the nerve roots within a narrowed spinal canal.

PURPOSE

The purpose of the current systematic review was to summarize existing literature reporting biomechanical changes in gait function that occur with LSS, and identify knowledge gaps that merit future investigation in this important patient population.

STUDY DESIGN/SETTING

This study is a systematic literature review.

OUTCOME MEASURES

The current study included biomechanical variables (e.g., kinematic, kinetic, and muscle activity parameters).

METHODS

Relevant articles were selected through MEDLINE, Scopus, Embase, and Web of Science. Articles were included if they: 1) included participants with LSS or LSS surgery, 2) utilized kinematic, kinetic, or muscle activity variables as the primary outcome measure, 3) evaluated walking or gait tasks, and 4) were written in English.

RESULTS

A total of 11 articles were included in the current systematic review. The patients with LSS exhibited altered gait function as compared to healthy controls. Improvements in some biomechanical variables were found up to one year after surgery, but most gait changes were found within one month after surgery.

CONCLUSIONS

Although numerous studies have investigated gait function in patients with LSS, gait alterations in joint kinetics and muscle activity over time remain largely unknown. In addition, there are limited findings of spinal kinematics in patients with LSS during gait. Thus, future investigations are needed to investigate longer-term gait changes with regard to spinal kinematics, joint kinetics, and muscle activity beyond one month after LSS surgery.

How does spinopelvic alignment influence short-term clinical outcomes after lumbar fusion in patients with single-level degenerative spondylolisthesis?

Context

Aims

Settings and Design

Materials and Methods

Statistical Analysis Used

Results

Conclusion

Risk Factors for Reoperation at Same Level after Decompression Surgery for Lumbar Spinal Stenosis in Patients with Diffuse Idiopathic Skeletal Hyperostosis Extended to the Lumbar Segments

Introduction

Diffuse idiopathic skeletal hyperostosis (DISH) extended to the lumbar segments (L-DISH) reportedly has adverse effects on the surgical outcomes of lumbar spinal stenosis (LSS). However, the risk factors in patients with L-DISH have not been clarified. The purpose of this study was to investigate the long-term risk factors for reoperation at the same level after decompression surgery alone for LSS in patients with L-DISH in a retrospective cohort study.

Methods

A postoperative postal survey was sent to 1,150 consecutive patients who underwent decompression surgery alone for LSS from 2002 to 2010. Among all respondents, patients who exhibited L-DISH by preoperative total spine X-ray were included in this study. We investigated risk factors for reoperation at the same level as the initial surgery among various demographic and radiological parameters, including the lumbar ossification condition and computed tomography (CT) or magnetic resonance imaging findings.

Results

A total of 57 patients were analyzed. Reoperations at the same level as that of the index surgery were performed in 10 patients (17.5%) and at 11 levels within a mean of 9.2 years. Cox proportional hazard regression analysis indicated that the independent risk factors for reoperation were a sagittal rotation angle ≥10° (adjusted hazard ratio: 5.17) and facet opening on CT (adjusted hazard ratio: 4.82). Neither sagittal translation nor the ossification condition in the lumbar segments affected reoperations.

Conclusions

A sagittal rotation angle ≥10° and facet opening on preoperative CT were risk factors for reoperation at the same level as that of the index surgery in patients with L-DISH. The surgical strategy should be carefully considered in those patients.

Laminectomy alone versus laminectomy with fusion for degenerative cervical myelopathy: a long-term study of a national cohort

PURPOSE

To compare patient-reported 5-year clinical outcomes between laminectomy alone versus laminectomy with instrumented fusion in patients with degenerative cervical myelopathy in a population-based cohort.

METHODS

All patients in the national Swedish Spine Register (Swespine) from January 2006 until March 2019, with degenerative cervical myelopathy, were assessed. Multiple imputation and propensity score matching based on clinicodemographic and radiographic parameters were used to compare patients treated with laminectomy alone with patients treated with laminectomy plus posterior-lateral instrumented fusion. The primary outcome measure was the European Myelopathy Score, a validated patient-reported outcome measure. The scale ranges from 5 to 18, with lower scores reflecting more severe myelopathy.

RESULTS

Among 967 eligible patients, 717 (74%) patients were included. Laminectomy alone was performed on 412 patients (mean age 68 years; 149 women [36%]), whereas instrumented fusion was added for 305 patients (mean age 68 years; 119 women [39%]). After imputation, the propensity for smoking, worse myelopathy scores, spondylolisthesis, and kyphosis was slightly higher in the fusion group. After imputation and propensity score matching, there were on average 212 pairs patients with a 5-year follow-up in each group. There were no important differences in patient-reported clinical outcomes between the methods after 5 years. Due to longer hospitalization times and implant-related costs, the mean cost increase per instrumented patient was approximately $4700 US.

CONCLUSIONS

Instrumented fusions generated higher costs and were not associated with superior long-term clinical outcomes. These findings are based on a national cohort and can thus be regarded as generalizable.

Decompression Using Minimally Invasive Surgery for Lumbar Spinal Stenosis Associated with Degenerative Spondylolisthesis: A Review

Lumbar spinal stenosis (LSS), which often occurs concurrently with degenerative spondylolisthesis (DS), is a common disease in the elderly population, affecting the quality of life of aged people significantly. Notwithstanding the frequently good effect of conservative therapy on LSS, a minority of the patients ultimately require surgery. Surgery for LSS aims to decompress the narrowed spinal canals with preservation of spinal stability. Traditional open surgery, either pure decompression or decompression with fusion, was considered effective for the treatment of LSS with or without DS. However, the long-term clinical outcomes of traditional open surgery are still unclear. Moreover, the disadvantages of conventional open surgery are extensive, examples including tissue injuries or secondary instability, with limited outcomes and significant reoperation rates. With the development and improvement of surgical tools, various minimally invasive spine surgery (MISS) methods, including indirect decompression techniques of interspinous process devices (IPDs) and direct decompression techniques such as microscopic spine surgery or endoscopic spine surgery (ESS), have been updated with enhancement. IPDs, such as Superion devices, were reported to behave with comparable physical function, disability, and symptoms outcomes to laminectomy decompression. As an emerging technique of MISS, ESS has beneficial hallmarks including minimal tissue injuries, reduced complication rates, and shortened recovery periods, thus gaining popularity in recent years. ESS can be classified in terms of endoscopic hallmarks and approaches. Predictably, with the continuous development and gradual maturity, MISS is expected to replace traditional open surgery widely in the surgical treatment of LSS associated with DS in the future.

Observer agreement in the choice of lumbar spine injection for pain management

BACKGROUND AND PURPOSE

Lumbar spine MRI can help guide the choice of corticosteroid injection in pain management. We investigated whether patient-reported symptom information from a questionnaire could improve agreement in the choice of type, level, and side of injection.

MATERIALS AND METHODS

In this prospective observational study, 120 patients (median age 64, 70 men) were recruited from patients referred for pain management. After informed consent, they completed electronic questionnaires that obtained symptom information for later use during MRI reviews. In 3 research arms, 6 radiologists chose injections that would ideally deliver corticosteroid to the presumed sources of pain in (1) MRI studies reviewed with symptom information from questionnaires, (2) MRI studies reviewed without symptom information, and (3) MRI reports. Blinded to questionnaire results, radiologists providing clinical care and interviewing patients chose ideal therapeutic injections to establish reference standards. Injections were categorized by type, level, and side and compared using percent agreement and kappa statistics. Interreading agreement was analyzed.

RESULTS

Compared to the reference standard, kappa agreements for injection types, levels, and sides were almost perfect when MRIs were reviewed knowing symptoms (0.85-0.93), fair without symptoms (0.23-0.35) (all P < .001) and fair in MRI reports (0.24-0.36) (all P < .001). Interreading kappa agreements were almost perfect knowing symptoms (0.82-0.90), but only moderate without symptoms (0.42-0.49) (all P < .001).

CONCLUSIONS

Radiologists reviewing lumbar spine MRI converged on the type, level, and side of ideal therapeutic injection whether they obtained symptom information from direct patient interview or electronic questionnaire. Observer agreement was significantly lower without symptom information.

Decompression alone versus decompression and instrumented fusion for the treatment of isthmic spondylolisthesis: a randomized controlled trial

OBJECTIVE

The most advocated surgical technique to treat symptoms of isthmic spondylolisthesis is decompression with instrumented fusion. A less-invasive classical approach has also been reported, which consists of decompression only. In this study the authors compared the clinical outcomes of decompression only with those of decompression with instrumented fusion in patients with isthmic spondylolisthesis.

METHODS

Eighty-four patients with lumbar radiculopathy or neurogenic claudication secondary to low-grade isthmic spondylolisthesis were randomly assigned to decompression only (n = 43) or decompression with instrumented fusion (n = 41). Primary outcome parameters were scores on the Roland Disability Questionnaire (RDQ), separate visual analog scales (VASs) for back pain and leg pain, and patient report of perceived recovery at 12-week and 2-year follow-ups. The proportion of reoperations was scored as a secondary outcome measure. Repeated measures ANOVA according to the intention-to-treat principle was performed.

RESULTS

Decompression alone did not show superiority in terms of disability scores at 12-week follow-up (p = 0.32, 95% CI -4.02 to 1.34), nor in any other outcome measure. At 2-year follow-up, RDQ disability scores improved more in the fusion group (10.3, 95% CI 3.9-8.2, vs 6.0, 95% CI 8.2-12.4; p = 0.006, 95% CI -7.3 to -1.3). Likewise, back pain decreased more in the fusion group (difference: -18.3 mm, CI -32.1 to -4.4, p = 0.01) on a 100-mm VAS scale, and a higher proportion of patients perceived recovery as showing "good results" (44% vs 74%, p = 0.01). Cumulative probabilities for reoperation were 47% in the decompression and 13% in the fusion group (p < 0.001) at the 2-year follow-up.

CONCLUSIONS

In patients with isthmic spondylolisthesis, decompression with instrumented fusion resulted in comparable short-term results, significantly better long-term outcomes, and fewer reoperations than decompression alone. Decompression with instrumented fusion is a superior surgical technique that should in general be offered as a first treatment option for isthmic spondylolisthesis, but not for degenerative spondylolisthesis, which has a different etiology.