Failed less invasive lumbar spine surgery as a predictor of subsequent fusion outcomes

Unilateral Biportal Endoscopic Posterior Cervical Foraminotomy: An Outcome Comparison With the Full-endoscopic Posterior Cervical Foraminotomy

STUDY DESIGN

Retrospective control study.

OBJECTIVE

To compare the curative effects of unilateral biportal endoscopic posterior cervical foraminotomy (UBE-PCF) with full-endoscopic posterior cervical foraminotomy (FPCF).

SUMMARY OF BACKGROUND DATA

There are few studies directly comparing outcomes between UBE-PCF and FPCF. The objective of this study was to compare outcomes between UBE-PCF and FPCF.

METHODS

A retrospective control study was conducted for 69 patients of cervical radiculopathy from July 2019 to December 2021. Clinical outcomes scores, including neck disability index, visual analog scale (VAS)-arm, and VAS-neck were evaluated. Serum creatine kinase levels and the size of the operating hole were measured.

RESULTS

Postoperative neck disability index, VAS-neck, and VAS-arm scores showed statistically significant improvement over preoperative scores ( P <0.01). The operating time was significantly shorter in the UBE-PCF group ( P <0.001). No significant differences were found in serum creatine kinase levels between the 2 groups ( P >0.05). The mean area of the operating hole was 1.47+0.05 cm 2 in the FPCF group and 1.79+0.11 cm 2 in the UBE-PCF group. The difference was statistically significant ( P <0.001).

CONCLUSIONS

Both UBE-PCF and FPCF are safe and effective procedures for cervical radiculopathy. Predictable and sufficient decompression could be achieved by UBE-PCF in a shorter operation time.

LEVEL OF EVIDENCE

Treatment Benefits Level III.

Current techniques of endoscopic decompression in spine surgery

Endoscopic spine surgery has become a practical, minimally invasive technique for decompression in patients with spinal disc herniation or stenosis. This review aimed to summarize the current techniques of endoscopic decompression technique in spine surgery and to discuss the benefits, limitations, and future perspectives of this minimally invasive technique. Endoscopic spine decompression surgery can be categorized according to the endoscopic property: percutaneous endoscopic (full-endoscopic), microendoscopic, and biportal endoscopic. It can also be classified based on the approach: transforaminal, interlaminar, anterior, posterior, and caudal approaches. Theoretically, each technique can be applied in the lumbar, cervical, and thoracic spine. The various endoscopic spine surgery techniques should be appropriately conducted according to the disease entities, level, and zone of pathologies. Although the current level of evidence is relatively low and the relevance of the technique is controversial, recent clinical results and the critical concept are promising. Development in optics, instruments, and approach will improve its safety and reduce technical complexity. In the meantime, high-quality clinical studies, including randomized trials and meta-analyses, are due for publication. Eventually, endoscopic spine surgery is expected to become the golden standard for spinal surgery.

The evidence-based approach for surgical complications in the treatment of lumbar disc herniation

PURPOSE

The purpose of this article is to review the evidence-based approach for surgical complications following disc herniation.

METHODS

A search of the primary English literature was conducted for research examining the outcomes and complications of surgical discectomy. Special regard was given to high-quality prospective randomized studies.

RESULTS

The most commonly reported complications of surgical treatment of disc herniation are included in this review. Medical complications, and surgical complications including infection, durotomy, neurological injury, symptomatic re-herniation, and revision surgery are defined and systematically reviewed in detail for incidence, evaluation, and management.

CONCLUSION

This article provides the clinician and surgeon with a review of the evidence-based evaluation and management of surgical complications following disc herniation, offering best practice guidelines for informed discussions with patients in shared decision-making.

Identifying subsets of patients with single-level degenerative disc disease for lumbar fusion: the value of prognostic tests in surgical decision making

BACKGROUND CONTEXT

Fusion surgery for degenerative disc disease (DDD) has become a standard of care, albeit not without controversy. Outcomes are inconsistent and a superiority over conservative treatment is debatable. Proper patient selection is key to clinical success, and a comprehensive understanding of prognostic tests does not currently exist.

PURPOSE

This study aimed to investigate the value of prognostic tests and sociodemographic factors in predicting outcomes following lumbar fusion surgery for DDD.

STUDY DESIGN

This is a retrospective analysis of prospectively collected data.

PATIENT SAMPLE

We included patients who underwent fusion surgery for DDD between 2010 and 2016.

OUTCOME MEASURES

The outcome measures included pre- and postoperative visual analog scale and Oswestry Disability Index scores.

MATERIALS AND METHODS

Prospectively collected patient data were reviewed for preoperative tests, perioperative data, and clinical outcomes. Prognostic tests used were discography, pantaloon cast test (PCT), Modic changes, and a summary of physical symptoms, coined "loading factor." By means of multivariate stepwise regression, prognostic factors that were useful in predicting outcomes were identified.

RESULTS

A total of 91 patients fit the inclusion criteria, with a mean follow-up of 33±16 months. Discography, Modic changes, and loading factor were of no value for predicting outcome scores (p>.05). A positive PCT predicted improved outcomes in back pain severity, but only in patients without prior surgery (p=.02). Demographic factors that showed a consistent reduction in back pain were female sex (p=.021) and no prior surgery at index level (p=.009). No other sociodemographic factors were of predictive value (p>.05).

CONCLUSIONS

In patients without prior surgery, the PCT appears to be the most promising prognostic tool. Other prognostic selection tools such as discography and Modic changes yield disappointing results. In this study, female patients and those without prior spine surgery appear to be most likely to benefit from fusion surgery for DDD.

A systematic literature review of time to return to work and narcotic use after lumbar spinal fusion using minimal invasive and open surgery techniques

BACKGROUND

Chronic low back pain is a common health problem for adult workers and causes an enormous economic burden. With the improvement of minimally invasive surgical techniques (MIS) in spinal fusion and the development of fusion devices, more lumbar operations are today being performed through a less invasive technique. When compared with open surgeries (OS), MIS has demonstrated better clinical outcomes including operation time, blood loss, complication rates and length of hospital stay. The aim of this review was to identify and summarize evidence on the time to return to work and the duration of post-operation narcotic use for patients who had lumbar spinal fusion operations using MIS and OS techniques.

METHODS

A systematic literature review was performed including studies identified from PubMed, EMBASE, the Cochrane Collaboration, and the Centre for Review and Dissemination (CRD) (January 2004–April 2014) for publications reporting on time to return to work and post-operation narcotic use after MIS or OS lumbar spinal fusion surgeries.

RESULTS

Out of a total of 36 included studies, 28 reported on the time to return to work and 17 on the narcotic use after MIS or OS. Four studies described the time to return to work directly comparing MIS and OS. Three studies, from the US, directly compared the duration of narcotic use between MIS- transforaminal lumbar interbody fusion (TLIF) and OS-TLIF. In addition to the time to return to work, 23 studies reported on the rate of return to work and the employment rate before and after surgery, and two Swedish studies presented sick leave data.

CONCLUSION

There is a gap of good quality data describing the time to return to work and narcotic use after lumbar spinal fusion operations using MIS or OS techniques. However, the current systematic literature review indicates that patients who have lumbar spinal fusion operations, with the MIS procedure, generally return to work after surgery more quickly and require less post-operation narcotics for pain control compared to patients who have OS.

Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up

PURPOSE

The purpose of this study is to assess safety and feasibility of intradiscal bone marrow concentrate (BMC) injections to treat discogenic pain as an alternative to surgery.

METHODS

A total of 26 patients (11 male, 15 female, aged 18-61 years, 13 single level, 13 two level) that met inclusion criteria of chronic (> 6 months) discogenic low back pain, degenerative disc pathology assessed by magnetic resonance imaging (MRI) with modified Pfirrmann grade of IV-VII at one or two levels, candidate for surgical intervention (failed conservative treatment and radiologic findings) and a visual analogue scale (VAS) pain score of 40 mm or more at initial visit. Initial Oswestry Disability Index (ODI) and VAS pain score average was 56.5 % and 80.1 mm (0-100), respectively. Adverse event reporting, ODI score, VAS pain score, MRI radiographic changes, progression to surgery and cellular analysis of BMC were noted. Retrospective cell analysis by flow cytometry and colony forming unit-fibroblast (CFU-F) assays were performed to characterise each patient's BMC and compare with clinical outcomes. The BMC was injected into the nucleus pulposus of the symptomatic disc(s) under fluoroscopic guidance. Patients were evaluated clinically prior to treatment and at three, six, 12 and 24 months and radiographically prior to treatment and at 12 months.

RESULTS

There were no complications from the percutaneous bone marrow aspiration or disc injection. Of 26 patients, 24 (92 %) avoided surgery through 12 months, while 21 (81 %) avoided surgery through two years. Of the 21 surviving patients, the average ODI and VAS scores were reduced to 19.9 and 27.0 at three months and sustained to 18.3 and 22.9 at 24 months, respectively (p ≤ 0.001). Twenty patients had follow-up MRI at 12 months, of whom eight had improved by at least one Pfirrmann grade, while none of the discs worsened. Total and rate of pain reduction were linked to mesenchymal stem cell concentration through 12 months. Only five of the 26 patients elected to undergo surgical intervention (fusion or artificial disc replacement) by the two year milestone.

CONCLUSIONS

This study provides evidence of safety and feasibility in the non-surgical treatment of discogenic pain with autologous BMC, with durable pain relief (71 % VAS reduction) and ODI improvements (> 64 %) through two years.

Role of a collagen membrane in adhesion prevention strategy for complex spinal surgeries

PURPOSE

Following lumbar spine surgery, postoperative complications can appear, including epidural adhesions. The formation of fibrosis around the dura mater can, on the one hand, lead to compression of the nerve roots with recurrent radicular pain and, on the other hand, can increase the risks of specific complications at spinal re-intervention (haematomas and dural breaches). The aim of this prospective monocentric study was to assess the safety of a new collagen antiadhesion membrane in vertebral osteotomy surgery where scar tissue and adhesions are important.

METHODS

Twenty-six patients consecutively operated for lumbar posterior subtraction osteotomy with implantation of a collagen-based anti-adhesion membrane were evaluated. Membrane tolerance was evaluated at the short and midterm during the regular follow-up.

RESULTS

At six months' follow-up, postoperative pain [visual analogue scale (VAS)] and disability (Oswestry Disability Index score) were significantly reduced 33.1 and 43.1%, respectively. These results were confirmed at 12-months' follow-up, with a decrease in pain of 39.9% and in disability of 49.3%. Amongst the observed postoperative complications was neither spinal fluid leak nor durotomy. Presence of the membrane was not related to complications. Two patients required further surgery for infection and nonunion at the osteotomised level. Adhesions to the dura mater were limited and thin, facilitating exposure.

CONCLUSIONS

This study shows good tolerance of the collagen based membrane for spinal osteotomy and its satisfactory use for preventing postoperative epidural adhesions. Good surgical practice associated with an anti-adhesion barrier may decrease fibrosis formation and improve postoperative functional results.

A minimally invasive posterior lumbar interbody fusion using percutaneous long arm pedicle screw system for degenerative lumbar disease

The aim of this study is to evaluate the therapeutic efficacy of patients with lumbar degeneration and instability treated with percutaneous pedicle screw fixation and minimally invasive lumbar interbody fusion. Twenty-one patients were selected in our hospital from November, 2012 to March, 2013. The patients with an average age 55.62 years, including 8 vertebral spondylolisthesis, 4 lumbar intervertebral disc herniation, and 9 lumbar spinal canal stenosis cases. All the patients were managed to take the lumbar MRI and radiographs. The comparison of preoperative and postoperative (3 days, 2 weeks, 3 months) VAS and ODI score were analyzed. The results indicated that VAS scores were 7.14 ± 0.79 before operation, and 5.19 ± 0.81 in 3 days after operation, 4 ± 0.84 after 2 weeks, and 2.67 ± 0.66 after 3 months. The pain was relieved, and the postoperative VAS score was lower than that before treatment (P < 0.05). ODI score was 55.8 ± 11.4 before operation, 47.38 ± 9.38 after 3 days, 41.38 ± 8.09 after 2 weeks, 35.76 ± 4.50 after 3 months. ODI score was obviously decreased (P < 0.05). In conclusion, percutaneous pedicle screw fixation combined with minimally invasive interbody fusion is a safe, effective, feasible minimally invasive spine operation, with worthy for spreading.