A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009

Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Methods

The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded.

Results

Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)).

Conclusion

Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis.

Decompression alone or decompression with fusion for lumbar spinal stenosis: a randomized clinical trial with two-year MRI follow-up

AIMS

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

METHODS

The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm2 at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis).

RESULTS

A total of 211 patients underwent surgery at a mean age of 66 years (69% female): 103 were treated by decompression with fusion and 108 by decompression alone. A two-year MRI was available for 176 (90%) of the eligible patients. A new stenosis at the operated and/or adjacent level occurred more frequently after decompression and fusion than after decompression alone (47% vs 29%; p = 0.020). The difference remained in the subgroup with a preoperative spondylolisthesis, (48% vs 24%; p = 0.020), but did not reach significance for those without (45% vs 35%; p = 0.488). Proximal adjacent level stenosis was more common after fusion than after decompression alone (44% vs 17%; p < 0.001). Restenosis at the operated level was less frequent after fusion than decompression alone (4% vs 14%; p = 0.036). Vertebral slip increased by 1.1 mm after decompression alone, regardless of whether a preoperative spondylolisthesis was present or not.

CONCLUSION

Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively.Cite this article: Bone Joint J 2022;104-B(12):1343-1351.

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes

STUDY DESIGN

Literature review.

OBJECTIVE

To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time.

METHODS

Literature databases were searched up to May 4^th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman's rho was used to determine the association between the Extreme Quotient (EQ) and year of publication.

RESULTS

We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= -.33, P= .09).

CONCLUSIONS

Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

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).

Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS)

Background

Previous studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery.

Methods

In this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery.

Discussion

With the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery.

Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00736-5.

Waiting for lumbar spinal stenosis surgery: suffering and a possibility to discover coping abilities

Objective

The objective of this study was to describe aspects of suffering related to being a person with LSS and how suffering is managed before LSS surgery.

Methods/design/setting

A Swedish county hospital. Interviews with 18 consecutive patients on the waiting list for LSS surgery. The themes that emerged from content analysis were further interpreted using Antonovsky salutogenic model as a sensitizing concept.

Results

The suffering from LSS before surgery included the main theme of experiencing an impaired physical and social life and struggling to be believed and taken seriously. This had coping strategies to manage symptoms before surgery: a good physician-patient relationship alleviates the burden of long waiting times; ways to manage pain and disability; ambiguous expectations and hope for recovery, and; ways to handle concerns before surgery).

Conclusion

Being a person with LSS includes suffering and a possibility to discover coping abilities or having support structures for doing so. Our study emphasizes the importance of a supportive dialogue, where physicians and patients make the suffering from LSS and care before LSS surgery more comprehensible and manageable.

Comparison between modified facet joint fusion and posterolateral fusion for the treatment of lumbar degenerative diseases: a retrospective study

Objective

To investigate the safety and effectiveness of modified facet joint fusion in the treatment of lumbar degenerative diseases and compare them with those of posterolateral fusion.

Methods

A total of 77 adult patients with lumbar degenerative disease diagnosed from January 2017 to February 2019 were considered for the present retrospective, nonrandomized, and controlled study. The patients were divided into two groups according to the fusion technique used during the surgery: the posterolateral fusion (PLF) group (n = 42) and the modified facet joint fusion (MFF) group (n = 35). The fusion rate, Oswestry Disability Index (ODI) score, visual analog scale (VAS) score for back pain and leg pain, Japanese Orthopedic Association (JOA) score, European Quality of Life–5 Dimensions (EQ-5D) score, length of hospital stay, length of operation, intraoperative blood loss, cost of hospitalization, complications and reoperations were compared between the 2 groups.

Results

All patients underwent a successful surgery, and all were followed up. No significant differences were found in age, sex, BMI, length of hospital stay, length of operation or cost of hospitalization. There were no significant differences in the preoperative or postoperative ODI or in the VAS, JOA, and EQ-5D scores between the MFF and PLF groups. However, the fusion rate of MFF group was higher than that of the PLF group (P < 0.05). What’s more, the MFF group had less intraoperative blood loss than the PLF group (P < 0.05). Complications related to iatrogenic nerve injury, vascular injury, epidural hematoma, intravertebral infection, and internal fixation did not occur in either group. None of the patients required reoperation.

Conclusions

Modified facet joint fusion is safe and efficient in the treatment of lumbar degenerative disease. The fusion rate of MFF was higher than PLF. The intraoperative blood loss of MFF was less than that of PLF. In addition, the therapeutic effect of MFF was not worse than that of PLF. Therefore, the MFF technique can be promoted in clinical treatment.

Full-Endoscopic Lumbar Decompression versus Open Decompression and Fusion Surgery for the Lumbar Spinal Stenosis: A 3-Year Follow-Up Study

Purpose

Compare the efficacy of full-endoscopic lumbar decompression surgery (FELDS) and open decompression and fusion surgery (ODFS) for lumbar spinal stenosis (LSS).

Patients and Methods

A retrospective analysis of 358 LSS patients treated by FELDS (“FELD” group) or ODFS (“open” group) was undertaken. There were 177 patients in the FELDS group with a mean age of 65.47±9.26 years and 181 patients in the open group with a mean age of 64.18±10.24 years. Duration of follow-up was 38.63±11.88 months in the FELDS group and 38.56±12.29 months in the open group. Visual analog scale (VAS) score, Oswestry Disability Index (ODI), and Modified MacNab criteria were used to access clinical outcomes. Surgical outcomes (duration of surgical procedure, blood loss, complications, duration of postoperative hospital stay (DOPHS), prevalence of revision procedures) were evaluated. Magnetic resonance imaging was used to evaluate the change in the Pfirrmann grade at adjacent segments.

Results

VAS score (leg and back) and ODI improved significantly in both groups (P<0.001). Success rate reached 86.55% and 90.60% in the FELDS group and open group (P>0.05), respectively. Procedure duration (84.12 vs 112.08 min), blood loss (7.97 vs 279.67 mL), and DOPHS (2.68 vs 4.78 days) of the FELDS group were significantly better than those of the open group (P<0.05). Total prevalence of complications and procedure revisions was 14.69% and 10.73% in the FELD group, respectively, but did not show a significant difference with that in the open group (12.15% and 9.39%, respectively). The Pfirrmann grade increased in 13.04% of adjacent segments in the FELDS group, significantly better than that in the open group (32.67%) (P<0.05).

Conclusion

FELDS had the same efficacy as ODFS for LSS treatment. FELDS had the advantages of minimal invasiveness, less surgical trauma, rapid recovery, and lower risk of degeneration of adjacent segments compared with that of ODFS.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Interobserver variance and patient heterogeneity influencing the treatment of grade I spondylolisthesis

BACKGROUND CONTEXT

Despite well done randomized clinical trials, the role of fusion as an adjunct to decompression for the treatment of patients with degenerative spondylolisthesis remains controversial. There is substantial variation in the use of fusion as well as the techniques used for fusion for a population of patients all described by a single ICD10 code.

PURPOSE

We sought to investigate the source of the variation in the perceived role of fusion by looking at surgeon as well as patient-specific factors.

STUDY DESIGN

Prospective cohort study examining the variability of recommendations from an expert panel of surgeons-based imaging and clinical vignettes.

PATIENT SAMPLE

Patients with degenerative spondylolisthesis and stenosis.

OUTCOME MEASURES

A six-category treatment schema based on level of invasiveness of proposed surgeries with one through three representing nonfusion strategies and categories four through six representing fusion strategies.

METHODS

The authors are conducting the ongoing spinal laminectomy vs instrumented pedicle screw II study in which patients with grade one degenerative spondylolisthesis and stenosis are randomized to two groups: a review group in which patients are treated as per recommendations of an expert panel and a nonreview group in which patients are treated as per the referring surgeon's preference. In the former (review group), clinical vignettes and radiographic studies were evaluated by an expert panel of spine surgeons. The panel then provided these recommendations to the referring surgeon. We investigated the underlying variability by looking both at the number of similar or different recommendations received by an individual patient (surgeon-related variability) as well as the number of similar or different recommendations offered by individual surgeons across the population of patients (patient heterogeneity). Agreement between surgeons for fusion vs nonfusion (Categories 1-3 vs 4-6) was calculated using a Kappa value from a mixed effects logistic regression model. We looked at Kappa for agreement and weighted Kappa for association of ratings on the ordinal 1 to 6 scale with a mixed effects linear regression model. Additionally, we analyzed the summary of data between patients after averaging the rater scores within patients. Similarly, we summarized the data between surgeons after averaging their scores over the patients that each surgeon reviewed.

RESULTS

One hundred and fourteen patients received 1,463 treatment recommendations. On average, fusion was recommended 58.5% of the time. Overall agreement was low, and perfect agreement on the need for fusion was seen in only 24 (21.1%) of patients. Kappa statistic for agreement on fusion was 0.378 (95% confidence interval 0.324-0.432). The average score across surgeons was 4.2 (0.6) with a range of 3 to 5.3. The most common single recommendation was for fusion with interbody fusion (40.8%) and the lowest was for decompression with noninstrumented fusion (0.5%).

CONCLUSIONS

We demonstrated variability in surgical approach when individual patients were evaluated by a panel of surgeons indicating that even "expert" surgeons disagree with each other regarding the need for fusion in individual patients. We were also able to demonstrate that individual patients received consistent recommendations that were very different from those received by other individuals evaluated by the same surgeons. This indicates that there is patient-related heterogeneity driving variability independent of surgeon factors.

Coflex interspinous process dynamic stabilization for lumbar spinal stenosis: Long-term follow-up

OBJECTIVE

To evaluate the long-term efficacy of Coflex dynamic stabilization device in the treatment of lumbar spinal stenosis.

METHODS

The clinical and imaging data of 73 patients undergoing Coflex dynamic stabilization surgery from July 2008 to June 2012 were retrospectively analyzed. All patients had a minimum of 8 years of follow-up. Clinical data were used to assess the clinical efficacy, and radiographic parameters were measured for evaluation of ASD.

RESULTS

56 Patients were followed up for 107.6 ± 13.3 months. The visual analogue scale of pain (VAS), Owestry disability index (ODI) and Japanese Orthopedic Association Scores (JOA) improved significantly after surgery. At 6 months after surgery and the last follow-up, lumbar range of motion (ROM) was significantly lower than that before surgery (P < 0.001). ROM was slightly increased at the last follow-up compared with that 6 months after operation (P > 0.05). ROM of adjacent segments increased at 6 months and at the last follow-up compared with that before surgery (P > 0.05). At 6 months after surgery, intervertebral space height (ISH) and intervertebral foramen height (IFH) of implanted segment was significantly higher than that before surgery (P < 0.05). At the last follow-up, there was a decrease in ISH and IFH (P > 0.05). During the follow-up period, a total of 11 patients (19.6%) experienced complications and 6 patients (10.7%) underwent secondary surgery.

CONCLUSION

Coflex interspinous process dynamic stabilization is effective in the long-term treatment of lumbar spinal stenosis, the ISH and IFH of implanted segment could be increased in a short period of time.

Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies

PURPOSE

We describe the incidence of tibial plateau fractures and the evolution of its management and financial burden in Belgium, perform a similar audit at University Hospitals Leuven, and define strategies to curb the increasing cost.

METHODS

National data on tibial plateau fractures were collected from the NIHDI and compared to our performance. Several clinical parameters, such as age, sex, treatment modality and length-of-stay, were included. The total healthcare costs are considered as the sum of hospitalization costs and ambulatory care costs.

RESULTS

Between 2006 and 2018, a total number of 35,226 tibial plateau fractures were diagnosed in Belgium and 861 at our center. The incidence increased 41% over time (mean 25/100,000 persons per year). The mean rate of surgery in Belgium was 37% and slightly decreased over time, due to a larger increase of non-operatively treated tibial plateau fractures. The rate of surgery at the UHL was 49%. Surprisingly, the average cost per patient was equal for operatively and non-operatively treated patients in Belgium, and driven by the length-of stay.

CONCLUSION

Since length-of-stay is the main driver of the total healthcare costs of tibial plateau fractures, guidelines on appropriate length-of-stay can help to decrease variability and curb the total healthcare costs, particularly of the non-operatively treated patients. Our performance was in line with this.

LEVEL OF EVIDENCE

Level IV.

Lumbar decompression and lumbar interbody fusion in the treatment of lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

The goal of this study was to review relevant randomized controlled trials in order to determine the efficacy of decompression and lumbar interbody fusion in the treatment of lumbar spinal stenosis.

METHOD

Using appropriate keywords, we identified relevant studies in PubMed, the Cochrane library, and Embase. Key pertinent sources in the literature were also reviewed, and all articles published through July 2019 were considered for inclusion. For each study, we assessed odds ratios, mean difference, and 95% confidence interval to assess and synthesize outcomes.

RESULT

Twenty-one randomized controlled trials were eligible for this meta-analysis with a total of 3636 patients. Compared with decompression, decompression and fusion significantly increased length of hospital stay, operative time and estimated blood loss. Compared with fusion, decompression significantly decreased operative time, estimated blood loss and overall visual analogue scale (VAS) scores. Compared with endoscopic decompression, microscopic decompression significantly increased length of hospital stay, and operative time. Compared with traditional surgery, endoscopic discectomy significantly decreased length of hospital stay, operative time, estimated blood loss, and overall VAS scores and increased Japanese Orthopeadic Association score. Compared with TLIF, MIS-TLIF significantly decreased length of hospital stay, and increased operative time and SF-36 physical component summary score. Compared with multi-level decompression and single level fusion, multi-level decompression and multi-level fusion significantly increased operative time, estimated blood loss and SF-36 mental component summary score and decreased Oswestry disability index score. Compared with decompression, decompression with interlaminar stabilization significantly decreased operative time and the score of Zurich claudication questionnaire symptom severity, and increased VAS score.

CONCLUSION

Considering the limited number of included studies, we still need larger-sample, high-quality, long-term studies to explore the optimal therapy for lumbar spinal stenosis.

Learning curve and clinical outcomes of percutaneous endoscopic transforaminal decompression for lumbar spinal stenosis

PURPOSE

To define and analyze the learning curve of percutaneous endoscopic transforaminal decompression (PETD) for lumbar spinal stenosis (LSS).

METHODS

From July 2015 to September 2016, 78 patients underwent PETD; one of whom was converted to open surgery, two were lost, and 75 were included in this study. Clinical results were assessed by using the Oswestry Disability Index (ODI) and visual analog scale (VAS). The learning curve was assessed by a logarithmic curve-fitting regression analysis. Of these 75 patients, 35 were defined as the "early" group, and 40 were defined as the "late" group for comparison.

RESULTS

The mean follow-up was 25.37 ± 4.71 months. The median operative time gradually decreased from 95 (interquartile range, IQR, 85-110) minutes for the early group to 70 (IQR, 60-80) minutes for the late group (P < .000), and an asymptote was reached after approximately 35 cases. After surgery, the VAS for leg pain (LP) and ODI decreased significantly and remained constant during the follow-up. However, the VAS of low back pain (LBP) increased mildly. The total complication rate was 6.6%. ODI, VAS of LP and of LBP, and complication rate did not significantly differ between two groups. Early ambulation and short hospital stay after surgery were achieved.

CONCLUSION

The learning curve of PETD for LSS was assessed and good clinical results were achieved. The surgeon's experience with this technique correlated with reduced operation time. Proper patient selection, familiarity with pathological anatomy, and manipulation under endoscopic view may shorten the learning curve and decrease complications.

Dynamic Changes of Cauda Equina Motion Before and After Decompressive Laminectomy for Lumbar Spinal Stenosis With Redundant Nerve Roots: Cauda Equina Activation Sign

STUDY DESIGN

Cross-sectional observational study (consecutive case series).

OBJECTIVES

The aim of this study was to define a criterion for achieving successful decompression of lumbar spinal stenosis (LSS) using intraoperative ultrasonography (IOUS) and to investigate the pathogenesis of redundant nerve roots (RNRs) based on the ultrasonographic findings.

METHODS

A total of 100 LSS patients (71 males, 29 females, mean age, 71 ± 8 years) with RNRs were enrolled as subjects in this study. IOUS was performed to evaluate pulsatile motion of the cauda equina (PMCE) just before and after decompressive laminectomy. To determine the decompression status of the cauda equina, the ultrasonographic findings were classified into 3 types on the basis of the presence or absence of PMCE: type 1, predecompression PMCE (-) to postdecompression PMCE (+); type 2, pre- and postdecompression PMCE (+); and type 3, pre- and postdecompression PMCE (-). The pathogenesis of RNRs was also investigated based on the ultrasonographic findings.

RESULTS

Around the stenosis, PMCE was almost always absent before decompression and appeared after decompression (type 1 in 94 patients, type 2 in 6, type 3 in 0). IOUS showed that, before decompression, the cauda equina was held at the stenosis and could not pulsate beyond the stenotic site, and after decompression, PMCE recovered in the craniocaudal direction, leading to the resolution of RNRs.

CONCLUSIONS

The emergence of PMCE can be a sign of successful decompression for LSS. Ultrasonographic findings support the notion that disturbance of PMCE around the stenosis is a basic component of the pathogenesis of RNRs.

Unilateral Laminotomy with Bilateral Decompression: A Case Series Studying One- and Two-Year Outcomes with Predictors of Minimal Clinical Improvement

OBJECTIVE

To assess factors that may predict failure to improve at 12 and 24 months after unilateral laminotomy with bilateral decompression (ULBD) for the management of lumbar spinal stenosis.

METHODS

A database of 255 patients who underwent microdecompression surgery by a single orthopedic spine surgeon between 2014 and 2018 was queried. Patients who underwent primary single-level ULBD of the lumbar spine were included. Visual analog scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI) results were collected preoperatively and at 12 and 24 months postoperatively. Demographic, radiographic, and operative factors were assessed for associations with failure to improve. Clinically important improvement was defined as reaching or surpassing the previously established minimum clinically important difference for ODI (12.8) and not requiring revision.

RESULTS

A total of 68 patients were included. Compared with preoperative values for back pain, leg pain, and ODI (7.32, 7.53, and 51.22, respectively), there were significant improvements on follow-up at 12 months (2.89, 2.23, and 22.40, respectively; P < 0.001) and 24 months (2.80, 2.11, 20.32, respectively; P < 0.001). Based on the defined criteria, 50 patients showed clinically important improvement after ULBD. Of the 18 patients who failed to improve, 12 required revision. Independent predictors of failure to improve included female sex (adjusted odds ratio, 5.06; 95% confidence interval, 1.49-21.12; P = 0.014) and current smoker status (adjusted odds ratio, 5.39; 95% confidence interval, 1.39-23.97; P = 0.018).

CONCLUSIONS

ULBD for the management of lumbar spinal stenosis leads to clinically important improvement that is maintained over a 24-month follow-up period. Female sex and tobacco smoking are associated with poorer outcomes.

Comparison of Nitinol and Titanium Nails Effectiveness for Lumbosacral Spine Fixation in Surgical Treatment of Degenerative Spine Diseases

Relevance. Surgical decompression and decompression with stabilization are highly effective for treatment of spinal canal stenosis at the level of lumbar spine. However, complications developing after application of rigid fixation systems resulted in active introduction of dynamic implants into clinical practice.

Purpose of the study — to compare effectiveness of nitinol and titanium nails for lumbosacral fixation in surgical treatment of degenerative spine diseases.

Materials and methods. 220 patients who underwent surgeries in 4 hospitals were randomized into two groups, each consisting of 110 patients (1:1 ratio): a group of patients who underwent stabilization of the vertebral motor segments with rods of nitinol with the required volume of decompression at the operation level and a group of patients who underwent stabilization of the vertebral motor segments with standard rods of titanium with the required volume of decompression at the intervention level. Patients suffered clinically significant spinal canal stenosis in one or two adjacent segments: from L3 to S1. Outcomes were evaluated during three years postoperatively by VAS scale for spine and lower limbs, and by ODI and SF-36 scales.

Results. All scales demonstrated better values in both groups of patients, namely, significant decrease of pain syndrome and improvement in mental and physical health. X-ray examination of all patients during the study period demonstrated restoration of lumbar lordosis. Group of patients with dynamic nails featured less complications rate related to metal implants including adjacent segment disease.

Conclusion. Transpedicular fixation of lumbosacral spine by nitinol nails is an effective technique allowing to preserve motion along with stable fixation.

Diagnosis and treatment of clavicular fractures in Belgium between 2006 and 2015

BACKGROUND

Clavicular fractures are common fractures of the shoulder girdle. The debate about whether these fractures should be treated conservatively or surgically is ongoing. This study describes the incidence of clavicular fractures in Belgium between 2006 and 2015 and how the surgical treatment rates have evolved during this time span.

METHODS

The study included all patients who were diagnosed with a clavicular fracture or surgically treated in Belgium. The Belgian National Institute for Health and Disability Insurance provided the data, which included the patients' age, sex, location, and time of injury for the entire Belgian population. The fracture incidences and surgical treatment rates for different population groups were assessed.

RESULTS

The incidence of clavicular fractures in Belgium increased from 56.5/100,000 persons/year in 2006 to 70.6/100,000 persons/year in 2015. The age-related incidence was U-shaped, with high incidences seen in both men and women younger than 18 and older than 70. The rate of surgically treated clavicular fractures increased by 190% between 2006 and 2015.

CONCLUSION

The incidence of clavicular fractures in Belgium increased between 2006 and 2015. In the male population, the fracture incidence increased among all age groups, but in the female population, the increase was most noted in elderly patients. Although the preferred treatment strategy of clavicular fractures continues to be debated, there is a high and increasing rate of surgical treatment in Belgium, with an increasing percentage of patients that are surgically treated as outpatients.

Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration

The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.

Spinal Surgeons' Opinions on Pre- and Postoperative Rehabilitation in Patients Undergoing Lumbar Spinal Fusion Surgery: A Survey-Based Study in the Netherlands and Sweden

STUDY DESIGN

A cross-sectional survey in the Netherlands and Sweden.

OBJECTIVE

To investigate Dutch and Swedish spinal surgeons' opinions on spinal fusion pre- and postoperative rehabilitation.

SUMMARY OF BACKGROUND DATA

Lumbar spinal fusion surgery is increasingly provided in patients with chronic low back pain. No guidelines however exist for pre- and postoperative rehabilitation and it is unknown what opinions spinal surgeons currently have about pre- and postoperative rehabilitation.

METHODS

A survey was circulated to Dutch and Swedish spinal surgeons. Reminders were sent after 4 and 8/9 weeks. Data of completed questionnaires of orthopedic- and neurosurgeons currently performing lumbar spinal fusion were included for analysis. Analysis comprised a range of descriptive summaries (numerical, graphical, and tabular).

RESULTS

Surveys of 34 Dutch and 48 Swedish surgeons were analyzed. Surgeons provided preoperative information on postoperative mobilization. Spinal fusion techniques varied, but technique did not influence postoperative treatment. Swedish surgeons recommended slightly faster mobilization than Dutch (direct vs. 1-day postoperative), and more activities the first day (sitting, standing, walking). Stair climbing was the most reported discharge criterion; however, time point to start varied. More Swedish surgeons referred to postoperative physiotherapy than Dutch (88% vs. 44%). Time-point to start home activities varied from 1 week to more than 6 months. Pain increase was allowed for less than 24 hours (The Netherlands 81%, Sweden 92%).

CONCLUSION

Findings reflect variability in lumbar spinal fusion rehabilitation in two European countries, especially in postoperative phase. The study proposes many new research topics and acts as starting point for future research valuable for the spinal community.

LEVEL OF EVIDENCE

3.

Does the Use of Epiduroscopic Lysis of Adhesions Reduce the Need for Spinal Cord Stimulation in Failed Back Surgery Syndrome? A Short-Term Pilot Study

BACKGROUND AND AIMS

Persistent low back pain after initially successful surgery that is not attributed to structural deficits is called failed back surgery syndrome (FBSS). When conservative and minimal invasive therapy fail, the recommended treatment is spinal cord stimulation (SCS). Because epidural fibrosis can be a contributing factor in the majority of FBSS patients, lumbosacral epiduroscopic lysis of adhesions may be considered as a less invasive alternative treatment option. We hypothesized that the use of epiduroscopic lysis of adhesions could reduce the need for SCS.

METHODS

A pilot study was performed in 35 consecutive patients with FBSS who underwent epiduroscopic lysis of adhesions. SCS was considered if epiduroscopic lysis of adhesions gave less than 50% global perceived effect (GPE) improvement after 15 months of follow-up. The GPE was measured 1 week and 6 months after the procedure.

RESULTS

Over a period of 69 months, 35 patients were included. After 15 months of follow-up, 43% of patients required SCS. Eight of the 15 patients who reported no short-term improvement needed SCS; those patients had severe epidural fibrosis. One week after epiduroscopic lysis of adhesions, 34%, 23%, and 43% of patients reported GPE improvement of > 50%, 20% to 50%, and < 20%, respectively. After 6 months, 5 patients were lost to follow-up, and 30%, 17%, and 16% of patients reported improvement of > 50%, 20% to 50%, and < 20%, respectively.

CONCLUSIONS

In this pilot study we observed a reduced need for SCS when lumbosacral epiduroscopic lysis of adhesions was used for patients with FBSS and magnetic resonance imaging-proven adhesions. These observations justify the evaluation of both treatment options in a prospective observational trial.

The Timing of Surgery Affects Return to Work Rates in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The objective of this study is to determine how time to surgery affects outcomes for degenerative lumbar stenosis (DLS) in a workers' compensation (WC) setting.

SUMMARY OF BACKGROUND DATA

WC subjects are known to be a clinically distinct population with variable outcomes following lumbar surgery. No study has examined the effect of time to surgery in this clinically distinct population.

MATERIALS AND METHODS

A total of 227 Ohio WC subjects were identified who underwent primary decompression for DLS between 1993 and 2013. We allocated patients into 2 groups: those that received operative decompression before and after 1 year of symptom onset. Our primary outcome was, if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for >6 months.

RESULTS

The early cohort had a significantly higher RTW rate [50% (25/50) vs. 30% (53/117); P=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that time to surgery remained a significant negative predictor of RTW status (P=0.04; odds ratio, 0.48; 95% confidence interval, 0.23-0.91). Patients within the early surgery cohort cost on average, $37,332 less in total medical costs than those who opted for surgery after 1 year (P=0.01). Furthermore, total medical costs accrued over 3 years after index surgery was on average, $13,299 less when patients received their operation within 1 year after symptom onset (P=0.01).

CONCLUSIONS

Overall, time to surgery had a significant impact on clinical outcomes in WC subjects receiving lumbar decompression for DLS. Patients who received their operation within 1 year had a higher RTW rate, lower medical costs, and lower costs accrued over 3 years after index surgery. The results presented can perhaps be used to guide surgical decision-making and provide predictive value for the WC population.

Prolonged Preoperative Opioid Therapy in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the impact of prolonged opioid use in the preoperative treatment plan of degenerative lumbar stenosis (DLS).

SUMMARY OF BACKGROUND DATA

Patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. The relative paucity of data on the relationship between preoperative opioid use and clinical outcomes in the workers' compensation (WC) population necessitates further study of this unique population.

METHODS

We identified 140 Ohio WC patients who underwent lumbar decompression and had received preoperative opioid prescriptions between 1993 and 2013. Our study cohorts were formed based on opioid use duration, which included short-term use (<3 months) and long-term use (>3 months). Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to determine the impact of the duration of preoperative opioid use on return to work rates. We also compared many secondary outcomes after surgery between both groups.

RESULTS

Patients on opioids less than 3 months had a significantly higher RTW rate compared with those who used opioids longer than 3 months [25/60 (42%) vs. 18/80 (23%); P = 0.01]. A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW (OR: 0.35, 95% CI: 0.13-0.89; P = 0.02). Patients who remained on opioid therapy longer than 3 months cost the Ohio Bureau of Workers' Compensation $70,979 more than patients who were on opioid therapy for less than 3 months (P < 0.01).

CONCLUSION

Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS.

LEVEL OF EVIDENCE

3.

Epidemiologic and Economic Burden Attributable to First Spinal Fusion Surgery: Analysis From an Italian Administrative Database

STUDY DESIGN

Retrospective large population based-study.

OBJECTIVE

Assessment of the epidemiologic trends and economic burden of first spinal fusions.

SUMMARY OF BACKGROUND DATA

No adequate data are available regarding the epidemiology of spinal fusion surgery and its economic impact in Europe.

METHODS

The study population was identified through a data warehouse (DENALI), which matches clinical and economic data of different Healthcare Administrative databases of the Italian Lombardy Region. The study population consisted of all subjects, resident in Lombardy, who, during the period January 2001 to December 2010, underwent spinal fusion surgery (ICD-9-CM codes: 81.04, 81.05, 81.06, 81.07, and 81.08). The first procedure was used as the index event. We estimated the incidence of first spinal fusion surgery, the population and surgery characteristics and the healthcare costs from the National Health Service's perspective. The analysis was performed for the entire population and divided into the main groups of diagnosis.

RESULTS

The analysis identified 17,772 [mean age (SD): 54.6 (14.5) years, 55.3% females] spinal fusion surgeries. Almost 67% of the patients suffered from a lumbar degenerative disease. The incidence rate of interventions increased from 11.5 to 18.5 per 100,000 person-year between 2001 and 2006, and was above 20.0 per 100,000 person-year in the last 4 years. The patients' mean age increased during the observational time period from 48.1 to 55.9 years; whereas the median hospital length of stay reported for the index event decreased. The average cost of the spinal fusion surgery increased during the observational period, from &OV0556; 4726 up to &OV0556; 9388.

CONCLUSION

The study showed an increasing incidence of spinal fusion surgery and costs from 2001 to 2010. These results can be used to better understand the epidemiological and economic burden of these interventions, and help to optimize the resources available considering the different clinical approaches accessible today.

LEVEL OF EVIDENCE

4.

Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers' Compensation Setting

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to compare outcomes in Workers' compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability.

SUMMARY OF BACKGROUND DATA

The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone.

METHODS

Three hundred sixty-four Ohio WC subjects were identified who underwent primary decompression (DC) or primary decompression and fusion (DC + F) for DLS alone between 1993 and 2013. Our primary outcome was if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for more than 6 months. A number of secondary outcomes were collected and analyzed.

RESULTS

The DC cohort had a significantly higher RTW rate [36% (83/227) vs. 25% (54/212); P = 0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that fusion with operative decompression remained a significant negative predictor of RTW status (P = 0.04; odds ratio: 0.58, 95% confidence interval: 0.34-0.99). Within the DC cohort, the rate of postoperative instability and subsequent fusion was 8%. Furthermore, subjects who received an adjunctive fusion cost of the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone.

CONCLUSION

Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population.

LEVEL OF EVIDENCE

3.

Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States.

METHODS

The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques.

RESULTS

From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R2 value between the number of surgeries and the S&P 500 Index was statistically significant (P ≤ .05).

CONCLUSIONS

The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends.

Characterization of facet joint cartilage properties in the human and interspecies comparisons

The facet joint, a synovial joint located on the posterior-lateral spine, is highly susceptible to degenerative changes and plays a significant role in back-related morbidities. Despite its significance, the facet is rarely studied and thus current treatment strategies are lacking. This study aimed to characterize, for the first time, the properties of human, pig, monkey, and rabbit lumbar facet cartilage providing much-needed design criteria for tissue engineering approaches. In this study, where possible, the facet's morphological, histological, mechanical, and biochemical properties were evaluated. Comparisons between the properties of the inferior and superior facet surfaces, as well as among spinal levels were performed within each species. In addition, interspecies comparisons of the properties were determined. The human facet joint was found to be degenerated; 100% of joint surfaces showed signs of pathology and approximately 71% of these were considered to be grade 4. Joint morphology varied among species, demonstrating that despite the mini-pig facet being closest to the human in terms of width and length, it was far more curved than the human or any of the other species. No notable differences were found in the mini-pig, monkey, and rabbit mechanical and biochemical properties, suggesting that these species, despite morphological differences, may serve as suitable animal models for studying structure-function relationships of the human facet joint. The characterization data reported in this study may increase our understanding of this ill-described joint as well as provide the foundation for the development of new treatments such as tissue engineering.

STATEMENT OF SIGNIFICANCE

This work provides the first comprehensive description of the properties of lumbar facet joint cartilage. Importantly, this work establishes that histological, biochemical, and mechanical properties are comparable between bipedal and quadrupedal animals, helping to guide future selection of appropriate animal models. This work also suggests that the human facet joint is highly susceptible to pathology. The mechanical properties of facet cartilage, found to be inferior to those of other synovial joints, provide a greater understanding of the joint's structure-function relationships as well as the potential etiology of facet joint pathology. Lastly, this work will serve as the foundation for the development of much-needed facet joint treatments, especially those based on tissue engineering approaches.

Decompression and coflex interlaminar stabilisation compared with conventional surgical procedures for lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

Decompression plus spinal fusion is one of the most common surgeries for the treatment of degenerative spine disease in older adults. However, complications caused by fusion surgery have been reported in some studies. Recently published studies have reported that coflex is a safe and viable option in the selection of instrumentation for spinal stabilisation. Our meta-analysis was conducted to investigate whether decompression and coflex results in better performance for lumbar spinal stenosis (LSS) patients when compared with decompression and fusion surgery.

METHOD

Web of Science, PubMed, Embase, and the Cochrane Library were comprehensively searched. Ten studies that compared coflex with fusion surgery were included in our meta-analysis. The PRISMA guidelines and Cochrane Handbook were applied to assess the quality of the results published in all included studies to ensure that the results of our meta-analysis were reliable and veritable.

RESULTS

The results of our meta-analysis showed that decompression and coflex was more effective than the control procedure in terms of the Oswestry Disability Index (ODI), length of hospital stay (LOS) and blood loss. However, no significant difference was found in visual analogue scale (VAS) and major device-related complications.

CONCLUSIONS

Compared with conventional decompression plus fusion surgery, coflex was not inferior in terms of functional clinical outcomes, including ODI and VAS pain score. Moreover, coflex showed less blood loss, shorter LOS and similar device-related complications compared to decompression plus fusion surgery. Therefore, the coflex interlaminar stabilisation device was found to be safe and effective compared to decompression plus fusion for the treatment of LSS.

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

BACKGROUND

The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials.

METHODS

We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusion group) or decompression surgery alone (decompression-alone group). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up.

RESULTS

There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P=0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompression-alone group, P=0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P<0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group.

CONCLUSIONS

Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone. (Funded by an Uppsala institutional Avtal om Läkarutbildning och Forskning [Agreement concerning Cooperation on Medical Education and Research] and others; Swedish Spinal Stenosis Study ClinicalTrials.gov number, NCT01994512.).

Body Mass Index and Risk for Clinical Lumbar Spinal Stenosis: A Cohort Study

STUDY DESIGN

A prospective cohort study that used a Swedish nationwide occupational surveillance program for construction workers (period of registration from 1971 to 1992). In all, 364,467 participants (mean age at baseline 34 yr) were included in the study.

OBJECTIVE

To determine whether overweight and obesity are associated with a higher risk of lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

During recent decades, LSS has become the most common indication for spine surgery, a change that coincides with a higher prevalence of obesity.

METHODS

A diagnosis of LSS was collected through individual linkage to the Swedish National Patient Register through December 31, 2011. Poisson regression models were employed to estimate multivariable-adjusted incidence rate ratios (IRRs) for LSS.

RESULTS

At baseline, 65% had normal weight (BMI [body mass index]: 18.5-24.99 kg/m), 29% were overweight (BMI: 25-29.99 kg/m), 5% were obese (BMI ≥30 kg/m), and 2% were underweight (BMI <18.5 kg/m). During 11,190,944 person-years of follow-up, with a mean of 31 years, 2381 participants were diagnosed with LSS. Compared with normal weight individuals, obese workers had an IRR of 2.18 (95% confidence interval, 1.87-2.53) for LSS and overweight workers had an IRR of 1.68 (95% confidence interval, 1.54-1.83). Workers who were underweight halved their risk of LSS (IRR: 0.52, 95% confidence interval, 0.30-0.90).

CONCLUSION

Obese and overweight persons are at a higher risk of developing LSS. Furthermore, our results indicate that obesity might be a novel explanation for the increased number of patients with clinical LSS.

LEVEL OF EVIDENCE

3.

Trends in the surgical treatment of lumbar spine disease in the United States

BACKGROUND CONTEXT

There is a lack of agreement among spine surgeons as to the best surgical treatment modality for many degenerative lumbar diseases. Although there are many studies examining trends in spinal surgery, specific studies reporting the variations in surgical treatment in the United States for these diseases are lacking.

PURPOSE

The aim of this study was to analyze trends in lumbar spinal fusion methods for common lumbar pathologies in the United States.

STUDY DESIGN/SETTING

National insurance database review: 2004-2009.

PATIENT SAMPLE

Data is taken from United Healthcare and represents more than 25 million patients.

OUTCOME MEASURES

No outcomes were measured in this study.

METHODS

Using a private insurance database, we identified patients who underwent one of five types of instrumented single-level lumbar spinal fusion for the 10 most common primary diagnoses. Surgery rates were reviewed from 2004 to 2009 and were stratified according to patient age, patient gender, and region in the United States. Poisson regression analysis was performed to determine regional and demographic differences in treatment modality. The authors received no funds in support of this work.

RESULTS

A total of 23,986 patients met our search criteria. Of the five fusion types, posterior lumbar interbody fusion (PLIF) with posterolateral fusion (PLF) was the most common (45%), followed by PLF (19%), anterior lumbar interbody fusion (ALIF, 16%), PLIF (10%), and ALIF with PLF (9%). There was a significant increase in PLIF with PLF (p<.0001), PLIF (p<.0001), PLF (p=.012), ALIF (p<.0001), and ALIF with PLF (p<.0001) from 2004 to 2009. After controlling for gender, there were significant differences between regions for all fusion types (p<.0001). The likelihood of a posterior fusion increased with age. Anterior fusions were more common in the 30- to 49-year-old age range than in patents older than 50. For patients in age groups older than 30, there was an increased number who underwent a circumferential fusion or an ALIF (p<.022). Fusion types were significantly different between genders (p<.026). Both genders had an overall increase in the number of fusions (p<.001) over the time period studied.

CONCLUSIONS

There are large differences in the United States for surgical treatment methods for lumbar spine pathology. These differences are likely multifactorial, with both patient and surgeon traits playing a role. Illustrating these differences will hopefully lead to outcomes research to determine the indications, efficacy, and appropriateness of these surgical methods, an important step on the path toward standardization of care.

Comparison of the lumbar disc herniation patients randomized in SPORT to 6,846 discectomy patients from NSQIP: demographics, perioperative variables, and complications correlate well

BACKGROUND CONTEXT

The Spine Patient Outcomes Research Trial (SPORT) is a highly referenced clinical trial that randomized patients with lumbar pathology to receive surgery or continued conservative treatment.

PURPOSE

The purpose of this study was to compare the SPORT lumbar disc herniation cohort and an analogous cohort from the National Surgical Quality Improvement Program (NSQIP) database.

STUDY DESIGN/SETTING

This is a retrospective cohort study comparing a national database population to a randomized clinical trial.

PATIENT SAMPLE

Elective lumbar discectomies from NSQIP between 2010 and 2012 were used.

OUTCOME MEASURES

Demographics were compared between the randomized SPORT cohorts (surgical and nonoperative) and NSQIP. Perioperative factors and complications were then compared between SPORT discectomy patients and NSQIP.

METHODS

Using current procedural terminology and International Classification of Diseases, ninth revision codes, all elective lumbar discectomies from NSQIP between 2010 and 2012 were identified. Where possible based on the published data and variables available in each cohort, the two populations were compared.

RESULTS

A total of 6,846 NSQIP discectomy patients were compared with the randomized SPORT surgical and nonoperative cohorts. Demographic comparisons showed that NSQIP patients were older (average age 48.2±14.5 years [mean±standard deviation] vs. 41.7±11.8 and 43.0±11.3 years, respectively [p<.001]) and had higher body mass index (29.6±6.2 kg/m(2) vs. 27.8±5.6 and 28.2±5.4 kg/m(2), respectively [p<.001]). No statistical differences existed for gender or race. Smoking status was not different between the SPORT nonoperative group and NSQIP but was higher in NSQIP compared with SPORT surgical patients (p=.020 by 7%). Comparisons of perioperative factors and complications between the SPORT surgical cohort and NSQIP showed no statistical difference in average operative time, length of stay, deep wound infections, wound dehiscence, total wound complications, or blood transfusions. Spine Patient Outcomes Research Trial superficial wound infection rates were higher than NSQIP (p=.029 by 1.4%). As expected, SPORT 1-year reoperation rates were higher than NSQIP 30-day rates (7% vs. 2%, p<.001).

CONCLUSIONS

Spine Patient Outcomes Research Trial lumbar disc herniation results are similar to those from a large national patient sample. Even statistically significant differences would be considered clinically similar. These findings support the generalizability of the SPORT lumbar disc herniation results.

Comparison of 368 patients undergoing surgery for lumbar degenerative spondylolisthesis from the SPORT trial with 955 from the NSQIP database

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare demographics and perioperative outcomes between the Spine Patient Outcomes Research Trial (SPORT) lumbar degenerative spondylolisthesis arm and a similar population from the National Surgical Quality Improvement Program (NSQIP) database.

SUMMARY OF BACKGROUND DATA

SPORT is a well-known surgical trial that investigated the benefits of surgical versus nonsurgical treatment in patients with various lumbar pathologies. However, the external validity of SPORT demographics and outcomes has not been fully established.

METHODS

Surgical degenerative spondylolisthesis cases were identified from NSQIP between 2010 and 2012. This population was then compared with the SPORT degenerative spondylolisthesis study. These comparisons were based on published data from SPORT and included analyses of demographics, perioperative factors, and complications.

RESULTS

The 368 surgical patients with degenerative spondylolisthesis in SPORT were compared with 955 patients identified in NSQIP. Demographic comparisons were as follows: average age and race (no difference; P > 0.05 for each), sex (9.1% more female patients in SPORT; P = 0.002), smoking status (6.6% more smokers in NSQIP; P = 0.002), and average body mass index (1.1 kg/m greater in NSQIP; P = 0.005). Larger differences were noted in what surgical procedure was performed (P < 0.001), with the most notable difference being that the NSQIP population was much more likely to include interbody fusion than the SPORT population (52.4% vs. 12.5%). Most perioperative factors and complication rates were similar, including average operative time, wound infection, wound dehiscence, postoperative transfusion, and postoperative mortality (no differences; P > 0.05 for each). Average length of stay was shorter in NSQIP compared with SPORT (3.7 vs. 5.8 d; P = 0.042).

CONCLUSION

Though important differences in the distribution of surgical procedures were identified, this study supports the greater generalizability of the surgical SPORT degenerative spondylolisthesis study based on similar demographics and perioperative outcomes when compared with patients from the NSQIP database.

LEVEL OF EVIDENCE

3.

Return to work after spinal stenosis surgery and the patient's quality of life

INTRODUCTION

The return to work of patients who undergo spinal surgery poses important medical and social challenge.

OBJECTIVES

1) To establish whether patients who undergo spinal stenosis surgery later return to work. 2) To establish the patient's attitude towards employment. 3) To assess the quality of life of the patients and its influence on their attitude to work.

MATERIALS AND METHODS

The study population consisted of 58 patients aged from 21 to 80 years (the mean age was 52.33±14.12). There were 29 women (50%) and 29 men (50%) in the group. The patients' quality of life was measured by the use of the WHOQOL-BREF instrument. Individual interviews were conducted 3 to 8 months (a mean of 5.72 months ±1.6) after the surgery.

RESULTS

1) Although 13 patients (22.3%) returned to work, 44 (75.9%) did not, these being manual workers of vocational secondary education. 2) Almost half of the patients (27 patients, i.e. 44%) intend to apply for disability pension, 16 patients (27.6%) consider themselves unfit to work, 22 patients (37.9%) do not feel like working again. 3) The quality of life of the patients decreased. Domain scores for the WHOQOL-BREF are transformed to a 0-100 scale. The mean physical health amounted to 60.67 (±16.31), the mean psychological health was 58.78 (±16.01), while the mean social relations with family and friends were 59.91 (±20.69), and the mean environment 59.62 (±12.48).

CONCLUSIONS

1) A total of 75% of the patients operated for lumbar spinal stenosis do not return to their preoperative work. Difficulties in returning to work and decreased quality of life are associated with female sex, lower-level education, hard physical work and low income. 2) Physical health, psychological health, social relations and environment decreased to the mean of approximately 60. 3) The quality of life of the patients who did return to work was similar to that of healthy people.

Time spent per patient in lumbar spinal stenosis surgery

PURPOSE

To examine the time needed from a surgeon's viewpoint to treat a patient operated for lumbar spinal stenosis. We firstly aimed to give evidence of the wide ranging duration of standardized procedure. Secondly, we investigated factors affecting the time allocated to each patient.

METHODS

438 medical records of patients operated on for lumbar decompression without fusion (2005-2011) were retrospectively examined. Primary data were operative time (OT, min), length of stay (LoS, days) and number of postoperative visits. A fourth parameter was calculated, the time spent per patient (TSPP, min) by summing the time spent in surgery, during inpatient and outpatient follow-up visits. Factors that influenced these medical resources were examined.

RESULTS

Median (5th-95th percentile) LoS was 5 days (2-15), OT 106 min (60-194), number of medical visits 5 (2-11) and TSPP 329 min (206-533). In descending order, factors predicting LoS were age, no. of levels, sex, operative technique, cardiovascular risk index, dural tear and haematoma. Factors predicting OT were number of levels, dural tear, foraminotomy, synovial cyst and body mass index. The statistical model could predict 36% of the TSPP variance. We recommend that surgeons add 35 min for each level, 29 min for patients over 65 years, 30 min for women, 132 min for dural tear and 108 min for epidural haematoma.

CONCLUSION

TSPP treated for lumbar spinal stenosis is highly variable, yet partially predictable. These data may help individual surgeons or heads of departments to plan their activities.