The Prolo Scale: history, evolution and psychometric properties

Antineuropathic Pain Management After Orthopedic Surgery: A Systematic Review

Background

The opioid crisis has become a present concern in the medical field. In an effort to address these complications, antineuropathic pain medications have been considered as alternatives to prescribed opioids.

Objective

This review focuses on the analgesic effects of neuromodulators, such as gabapentin, duloxetine, and pregabalin, that provide room for less dependence on narcotic analgesics following orthopedic surgery.

Methods

During the database searches, 1,033 records were identified as a preliminary result. After duplicates were removed, an initial screen of each article was completed which identified records to be removed due to absence of a full-text article. Articles were excluded if they were not either prospective or retrospective, showcased an irrelevant medication (such as tricyclic antidepressants) which are not pertinent to this review, or deemed to be unrelated to the topic.

Results

Ultimately, 19 articles were selected. Three different drugs, gabapentin, pregabalin, and duloxetine, were analyzed to compile data on the effectiveness of preventing opioid overuse and addiction following hand surgery. This review identifies potential evidence that peri-operative gabapentin, pregabalin, and duloxetine administration decreases post-operative pain and lowers opioid dependency.

Conclusion

Gabapentin, pregabalin, and duloxetine have potential to further decrease post-operative pain and lower opioid dependency. This review creates an opening for further research in hand surgery to assess an updated protocol for pain management to reduce opioid dependency.

Surgical management of thoracolumbar junction fractures: An evidence-based algorithm

Background

The management of thoracolumbar junction (TLJ) fractures, involving the restoring anatomical stability and biomechanics properties, still remains a challenge for neurosurgeons.Despite the high frequency of these injuries, specific treatment guidelines, set on biomechanical properties, have not yet been assumed. The present study is meant to propose an evidence-based treatment algorithm. The primary aim for the protocol validation was the assessment of postoperative neurological recovery. The secondary objectives concerned the evaluation of residual deformity and rate of hardware failure. Technical nuances of surgical approaches and drawbacks were further discussed.

Methods

Clinical and biomechanical data of patients harboring a single TLJ fracture, surgically managed between 2015 and 2020, were collected. Patients' cohorts were ranked into 4 groups according to Magerl's Type, McCormack Score, Vaccaro PLC point, Canal encroachment, and Farcy Sagittal Index. The outcome measures were the early/late Benzel-Larson Grade and postoperative kyphosis degree to estimate neurological status and residual deformity, respectively.

Results

32 patients were retrieved, 7, 9, 8, and 8 included within group 1, 2, 3, and 4, respectively. Overall neurological outcomes significantly improved for all patients at every follow-up stage (p ​< ​0.0001). Surgeries gained a complete restoration of post-traumatic kyphosis in the entire cohort (p ​< ​0.0001), except for group 4 which experienced a later worsening of residual deformity.

Conclusions

The choice of the most appropriate surgical approach for TLJ fractures is dictated by morphological and biomechanical characteristics of fracture and the grade of neurological involvement. The proposed surgical management protocol was reliable and effective, although further validations are needed.

[Treatment of trauma-related vertebral body fractures of the thoracic and lumbar spine with orthotic devices : A review]

BACKGROUND

Trauma-related fractures of the thoracic and lumbar spine occur after exposure to high kinetic energy. To assign patients to the correct kind of treatment the AO spine classification is used.

OBJECTIVE

The aim was to describe the role of orthotic devices in the treatment of thoracic and lumbar fractures in the nondegenerative spine.

MATERIAL AND METHODS

A review of the literature was carried out according to the PRISMA protocol (Preferred Reporting Items for Systematic reviews and Meta-Analyses) in PubMed, ScienceDirect, Cochrane and Google.Scholar. A total of 118 potentially important publications were found and 16 studies with a prospective study design could be included in this analysis. RoB 2 (Cochrane Risk of Bias tool in the second Version) in the case of randomized studies and the ROBINS‑I (Risk Of Bias In Nonrandomised Studies of Interventions) for nonrandomized studies were used to assess publication quality. The level of evidence was determined according to AHCPR (Agency for Health Care Policy and Research).

RESULTS

In the case of fractures (AO types A0-A3) without degenerative changes in the bone structure of the thoracic and lumbar spine without indications for operative procedure, conservative treatment with analgesia, physiotherapy and early mobilization is recommended and orthotic treatment is not superior. Surgical treatment, even in cases where conservative treatment was possible, led to improved functionality and pain sensation faster but there were no differences in the long-term results. Assessing the neurological functional deficit, the functional success of the treatment and the kyphosis angle were measured in different ways, reducing the extent of comparability. Although mainly a level of evidence Ib-IIa could be assigned, nearly all included studies had a high risk of bias.

CONCLUSION

In individual cases treatment with an orthotic device could be a helpful add-on in conservative treatment of fractures in the thoracic and lumbar spine. A treatment with orthotic devices alone cannot be recommended in these cases.

Postoperative clinicoradiological outcome of pott's spine

Introduction:

Tuberculosis (TB) is one of the main diseases impacting humanity. Fifty percent of all the cases of skeletal TB belong to spinal TB (STB), and it is also the most common form of TB. In India, patients usually present late after the onset of neurological symptoms, for which surgical management is essential for recovery. In our study, we have evaluated the outcome of forty patients of STB who underwent posterior decompression and instrumentation.

Methods:

Forty patients with STB who underwent posterior decompression and instrumentation were reviewed. All cases were followed up for 18 months. The groups were compared by parameters such as improvement in pain, improvement in kyphosis, and neurological recovery. Visual Analog Scale (VAS) score and american spinal cord injury assosciation (ASIA) score are used for the assessment.

Results:

VAS score was significantly decreased postoperatively (mean: 1.28) as compared to preoperative values (mean: 7.25). Erythrocyte sedimentation rate (ESR) was significantly decreased postoperatively (mean: 30.95) as compared to preoperative values (76.15). Cobb's angle was significantly decreased immediate postoperatively (mean: 7.8) as compared to preoperative values (mean: 24.8). There was no deterioration of neurological symptoms in any of the patients.

Conclusion:

Surgical intervention in Pott's spine with posterior decompression and stabilization, whenever indicated, gives good improvement in pain, decreases kyphotic deformity, and in most cases, also improves neurology.

Three-Dimensional Volumetric Changes and Clinical Outcomes after Decompression with DIAM™ Implantation in Patients with Degenerative Lumbar Spine Diseases

Background and objectives: The prevalence of degenerative lumbar spine diseases has increased. In addition to standard lumbar decompression and/or fusion techniques, implantation of interspinous process devices (IPDs) can provide clinical benefits in highly selected patients. However, changes in spinal structures after IPD implantation using magnetic resonance imaging (MRI) have rarely been discussed. This volumetric study aimed to evaluate the effect of IPD implantation on the intervertebral disc and foramen using three-dimensional assessment. Materials and Methods: We retrospectively reviewed patients with lumbar degenerative disc diseases treated with IPD implantation and foraminotomy and/or discectomy between January 2016 and December 2019. The mean follow-up period was 13.6 months. The perioperative lumbar MRI data were processed for 3D-volumetric analysis. Clinical outcomes, including the Prolo scale and visual analog scale (VAS) scores, and radiographic outcomes, such as the disc height, foraminal area, and translation, were analyzed. Results: Fifty patients were included in our study. At the one-year follow-up, the VAS and Prolo scale scores significantly improved (both p < 0.001). The disc height and foraminal area on radiographs also increased significantly, but with limited effects up to three months postoperatively. MRI revealed an increased postoperative disc height with a mean difference of 0.5 ± 0.1 mm (p < 0.001). Although the mean disc volume difference did not significantly increase, the mean foraminal volume difference was 0.4 ± 0.16 mm³ (p < 0.05). Conclusions: In select patients with degenerative disc diseases or lumbar spinal stenosis, the intervertebral foramen was enlarged, and disc loading was reduced after IPD implantation with decompression surgery. The 3D findings were compatible with the clinical benefits.

Change in the dimensions of the lumbar area muscles after surgery: MRI analysis

OBJECTIVE:

This study aims to assess the change in the dimensions of the lumbar muscles in patients with chronic lower back pain using Magnetic Resonance Imaging (MRI) and to determine pre/post effects of surgery.

METHODS:

We enrolled 28 individuals (13F/15M; age: 45.39±11.56 years) whose L2–S1 muscle measurements were obtained using MRI, before and at follow-up 6–12 months after surgery. The control group comprising 37 individuals (18F/19M; age: 34.41±10.72 years) who had no lumbar pathology but for whom retrospective archive images were available. In the axial MRI analysis, the cross-sections of m.multifidus, mm.erector spinae and m.psoas major on both sides were measured with the ‘closed polygon’ technique.

RESULTS:

The L2–3 and L4–5 levels of the m.multifidus on the right side, the L2–3, L4–5 and L5–S1 levels of the m.multifidus and the L5–S1 levels of the mm. erector spinae on the left side cross-sectional areas were significantly lower than the control group (p<0.05). The right-side m.multifidus and the left-side mm.erector spinae sectional areas were significantly lower than the pre-surgery values at the L5–S1 levels (p<0.05).

CONCLUSION:

This study demonstrated that chronic lower back pain causes atrophy in the lumbar muscles and established the existence and continuity of atrophy after surgery.

Patient-Reported Outcome Measures in Neurosurgery: A Review of the Current Literature

BACKGROUND

Patient-reported outcome measures (PROMs) play an important role in the evaluation of health outcomes, quality of life, and satisfaction, and have been successfully utilized in many areas of clinical medicine and surgical practice. The prevalence of PROMs in neurosurgery is not known.

OBJECTIVE

To review the PROMs that have been utilized in the published neurosurgery literature to date.

METHODS

Articles were searched in MEDLINE, EMBASE, HMIC Health Management Information Consortium, PsycARTICLES, and PsycINFO using search terms related to neurosurgery and PROMs, published from 1806 to August 2016. A total of 268 articles were identified that were stratified by the inclusion and exclusion criteria leading to a total of 137 articles. Twenty-six PROMs, involving both adult and pediatric populations, were identified.

RESULTS

A large number of generic and disease-specific PROMs are used in the neurosurgical literature. Generic PROMs are usually nonspecific measures of health status. Disease-specific PROMs may not address issues relevant to neurosurgical procedures. There are very few neurosurgery-specific PROMs that take into account the impact of a neurosurgical procedure on a specific condition.

CONCLUSION

PROMs that currently feature in the neurosurgical literature may not address the specific outcomes relevant to neurosurgical practice. There is an emergent need for generic and disease-specific PROMs to be validated in neurosurgical patients and neurosurgery-specific PROMs developed to address unmet needs of patients undergoing neurosurgical procedures.

Clinical Outcomes after Microdiscectomy for Recurrent Lumbar Disk Herniation: A Single-Center Study

BACKGROUND

Revision discectomy is the principal procedure for recurrent lumbar disk herniation (RLDH). The clinical outcomes after this procedure are as good as or slightly poorer than those produced by primary discectomy. In this study, the clinical outcomes of patients treated with microsurgical discectomy for RLDH were analyzed.

METHODS

We examined 179 patients undergoing lumbar microdiscectomy surgery for RLDH. The visual analogue scale (VAS), Prolo scoring system, and Oswestry Disability Index (ODI) were used for evaluating the improvement of symptoms and functional outcomes.

RESULTS

Among 179 patients, 101 (56%) obtained good and excellent Prolo scores (group 1), while 78 (44%) obtained fair or poor results (group 2). There was no significant difference between the groups regarding age (P=0.515), gender (P=0.545), body mass index (P=0.523), diabetes mellitus (P=0.074), smoking (P=0.100), interval between primary and revision surgeries (P=0.749), and surgical outcomes (P=0. 749). However, significant improvements were achieved in VAS scores for back (P=0.197) and radicular pain (P=0.606), as well as ODI scores (P= 0.000). Based on the findings, only ODI scores showed a significant inter-group difference in the 12-month follow-up (P=0.038).

CONCLUSION

Limited microsurgical discectomy could be considered as the main surgical method in patients with RLDH without overt instabilities.

Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis: long-term results and predictive factors

BACKGROUND

The microsurgical unilateral laminotomy (MUL) technique for bilateral decompression of lumbar spinal stenosis (LSS) is a less destabilizing alternative to laminectomy and leads to good short-term outcomes. However, little is known about the long-term results including predictive factors.

METHODS

Medical records of patients who underwent MUL for LSS decompression between 2005 and 2010 were reviewed, and a questionnaire was distributed to complement the long-term outcome data. The study population consisted of 176 patients including 17 patients with stable grade I spondylolisthesis. Complications and reoperations were meticulously analyzed. Clinical outcome was measured using a modified Prolo scale and was further dichotomized in good vs. poor outcome. Predictive factors were obtained from uni- and multivariate analyses.

RESULTS

The median age of the cohort was 70.0 years and the follow-up 71.7 months. Complications occurred in 5.1 % of the patients. The overall reoperation rate was 17.0 %, including surgery, which was exclusively performed at other levels in 4.0 %. The reoperation rate for fusion was 4.5 %. Good neurogenic claudication outcome faded from 98.3 % at hospital discharge to 47.2 % at 6 years. Multivariate analysis identified previous lumbar operation as a potential independent predictor of a reoperation; potential independent predictors of poor long-term claudication outcome were older age, female gender, higher body mass index (BMI) and tobacco smoking.

CONCLUSIONS

In our experience, the long-term reoperation rate after MUL for LSS is not negligible and higher in previously operated patients. It seems like the good initial clinical results after MUL may fade over time, and several patient-related predictive factors including potentially modifiable obesity and tobacco smoking seem to play an important role.

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

PURPOSE

It is not uncommon for patients to undergo less invasive spine surgery (LISS) prior to succumbing to lumbar fusion; however, the effect of failed LISS on subsequent fusion outcomes is relatively unknown. The aim of this study was to test the hypothesis that patients who suffered failed LISS would afford inferior subsequent fusion outcomes when compared to patients who did not have prior LISS.

METHODS

After IRB approval, registry from a spine surgeon was queried for consecutive patients who underwent fusion for intractable low back pain. The 47 qualifying patients were enrolled and split into two groups based upon a history for prior LISS: a prior surgery group (PSG) and a non-prior surgery group (nPSG).

RESULTS

Typical postoperative outcome questionnaires, which were available in 80.9% of the patients (38/47) at an average time point of 40.4 months (range, 13.5-66.1 months), were comparatively analysed and failed to demonstrate significant difference between the groups, e.g. PSG v. nPSG: ODI--14.6 ± 10.9 vs. 17.2 ± 19.4 (P = 0.60); SF12-PCS--10.9 ± 11.0 vs. 8.7 ± 12.4 (p = 0.59); bNRS--3.0 (range -2-7) vs. 2.0 (range -3-8) (p = 0.91). Patient satisfaction, return to work rates, peri-operative complications, success of fusion and rate of revision surgery were also not different.

CONCLUSIONS

Although limited by size and retrospective design, the results of this rare investigation suggest that patients who experience a failed LISS prior to undergoing fusion will not suffer inferior fusion outcomes when compared to patients who did not undergo prior LISS.