MOS short form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience

Clinical values of oblique lumbar interbody fusion on the treatment of single-level degenerative lumbar diseases

Objectives

Minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) and oblique lumbar interbody fusion (OLIF) are increasingly replacing traditional approaches. This study aimed to compare the clinical outcomes of OLIF and Mis-TLIF in treating single-level degenerative lumbar diseases.

Methods

Patients with single-level degenerative lumbar diseases underwent either OLIF (30 patients) or Mis-TLIF (30 patients). Surgical data, including operation time, blood loss, postoperative drainage, and postoperative bed rest duration, were collected. Clinical outcomes were assessed using the Oswestry disability index, the visual analog scale scores for low back pain and leg pain, and Japanese Orthopaedic Association scores for daily ability, along with monitoring of complications.

Results

The OLIF group showed significantly shorter operative times, less blood loss, reduced postoperative drainage, and shorter bed rest durations than the Mis-TLIF group. At the 1-month follow-up, OLIF patients also demonstrated significantly better clinical outcome scores than Mis-TLIF patients. No significant differences were observed between OLIF and Mis-TLIF patients before surgery and after 3 months. Furthermore, lumbar lordosis and disc height were significantly greater in the OLIF group at the final follow-up.

Conclusions

Both OLIF and Mis-TLIF achieved satisfactory and effective long-term clinical outcomes for single-level lumbar degenerative diseases. However, OLIF resulted in less tissue damage, reduced bleeding, better short-term clinical outcomes, and improved recovery of segmental lordosis compared to Mis-TLIF. Therefore, OLIF appears to be the preferable option over Mis-TLIF.

Effect of Preoperative Motor Weakness on Postoperative Clinical Outcomes in Patients Undergoing Cervical Disk Replacement

STUDY DESIGN

This is a retrospective review.

OBJECTIVE

To examine the effect of preoperative motor weakness on clinical outcomes in patients undergoing cervical disk replacement (CDR).

SUMMARY OF BACKGROUND DATA

Studies examining the effect of preoperative motor weakness on postoperative clinical outcomes in CDR are limited.

METHODS

Patient cohorts were based on documented upper-extremity motor weakness on physical exam versus no motor weakness. Demographics, perioperative characteristics, and preoperative patient-reported outcome measures (PROMs) were compared using univariate inferential statistics. PROMs consisted of Visual Analog Pain Scale-Neck (VAS-N), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), VAS-Arm (VAS-A), 12-Item Short Form (SF-12) Physical Component Score (PCS), Oswestry Neck Disability Index (NDI), and SF-12 Mental Component Score (MCS). Postoperative PROMs were collected at the 6-week, 12-week, 6-month, and final follow-up up to 1-yeartime points, and intercohort minimum clinically important difference (MCID) achievement was compared through multivariable linear logistic regression adjusting for significant differences in preoperative characteristics.

RESULTS

A total of 118 patients formed cohorts based on documented upper-extremity weakness (n=73) versus no weakness (n=45). The average time to postoperative follow-up was 9.7±7.0 mo. The differences in insurance type between the 2 cohorts were significant (P<0.042). Perioperative diagnosis of foraminal stenosis was significantly more common in the motor weakness cohort (P<0.013). There were no differences in reported PROMs between cohorts. Patients with motor weakness reported significant MCID achievement for PROMIS-PF at 6-/12-weeks (P<0.012, P<0.041 respectively), SF-12 PCS at 6-months (P<0.042), VAS-N at final follow-up (P<0.021), and NDI at final follow-up (P<0.013).

CONCLUSIONS

CDR patients with preoperative muscle weakness achieved MCID across several PROMs compared with patients without muscle weakness. Patients with motor weakness reported greater improvement in mental health, pain, and disability as early as 6 weeks and up to 1 year after CDR. This information serves to inform physicians that motor weakness may not indicate a negative overall outcome.

Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial

BACKGROUND AND OBJECTIVES

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW.

METHODS

In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model.

RESULTS

A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively.

CONCLUSION

Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Confirmatory study of the usefulness of quantum molecular resonance and microdissectomy for the treatment of lumbar radiculopathy in a prospective cohort at 6 months follow-up

OBJECTIVES

Low back pain is a common musculoskeletal complaint and while prognosis is usually favorable, some patients experience persistent pain despite conservative treatment and invasive treatment to target the root cause of the pain may be necessary. The aim of this study is to evaluate patient outcomes after treatment of lumbar radiculopathy (LR) with quantum molecular resonance radiofrequency coblation disc decompression and percutaneous microdiscectomy with grasper forceps (QMRG).

METHODS

This prospective cohort study was carried out in two Spanish hospitals on 58 patients with LR secondary to a contained hydrated lumbar disc hernia or lumbar disc protrusion of more than 6 months of evolution, which persisted despite conservative treatment with analgesia, rehabilitation, and physiotherapy, and/or epidural block, in the previous 2 years. Patients were treated with QMRG and the outcomes were measured mainly using the Douleur Neuropathique en 4 Questions, Numeric Rating Scale, Oswestry Disability Index, SF12: Short Form 12 Health Survey, Patient Global Impression of Improvement, Clinical Global Impression of Improvement, and Medical Outcomes Study Sleep Scale.

RESULTS

Patients who received QMRG showed significant improvement in their baseline scores at 6 months post-treatment. The minimal clinically important difference (MCID) threshold was met by 26-98% of patients, depending on the outcome measure, for non-sleep-related outcomes, and between 17 and 62% for sleep-related outcome measures. Of the 14 outcome measures studied, at least 50% of the patients met the MCID threshold in 8 of them.

CONCLUSION

Treatment of LR with QMRG appears to be effective at 6 months post-intervention.

Quantum Molecular Resonance Radiofrequency Disc Decompression and Percutaneous Microdiscectomy for Lumbar Radiculopathy

Within the practice of pain management, one of the most commonly encountered events is low back pain. Lumbar radiculopathy (LR) is a pain syndrome caused by the compression or irritation of the nerve roots in the lower back due to lumbar disc herniation, vertebra degeneration, or foramen narrowing. Symptoms of LR include low back pain that propagates toward the legs, numbness, weakness, and loss of reflexes. The aim of this study is to assess the long-term effectiveness of quantum molecular resonance disc decompression and its combination with a percutaneous microdiscectomy using Grasper© forceps (QMRG) in patients with persistent lumbar radiculopathy (LR) in relation to patient physical stress status. The main outcome measures of this prospective observational study were DN4, NRS, ODI, SF12, PGI, CGI, and MOS Sleep Scale. An improvement 12 months post-intervention was observed in patients without physical stress, presenting better overall results. The mean change was over the minimal clinically important difference in 64.3% of outcome measures studied for the whole sample. QMRG appears to be an effective treatment option for LR, but a reduction in physical stress is needed to ensure long-term effectiveness.

A systematic review of anterior lumbar interbody fusion (ALIF) versus posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), posterolateral lumbar fusion (PLF)

PURPOSE

The rate of elective lumbar fusion has continued to increase over the past two decades. However, there remains to be a consensus on the optimal fusion technique. This study aims to compare stand-alone anterior lumbar interbody fusion (ALIF) with posterior fusion techniques in patients with spondylolisthesis and degenerative disc disease through a systematic review and meta-analysis of the available literature.

METHODS

A systematic review was performed by searching the Cochrane Register of Trials, MEDLINE, and EMBASE from inception to 2022. In the two-stage screening process, three reviewers independently reviewed titles and abstracts. The full-text reports of the remaining studies were then inspected for eligibility. Conflicts were resolved through consensus discussion. Two reviewers then extracted study data, assessed it for quality, and analysed it.

RESULTS

After the initial search and removal of duplicate records, 16,435 studies were screened. Twenty-one eligible studies (3686 patients) were ultimately included, which compared stand-alone ALIF with posterior approaches such as posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), and posterolateral lumbar fusion (PLF). A meta-analysis showed surgical time and blood loss was significantly lower in ALIF than in TLIF/PLIF, but not in those who underwent PLF (p = 0.08). The length of hospital stay was significantly shorter in ALIF than in TLIF, but not in PLIF or PLF. Fusion rates were similar between the ALIF and posterior approaches. The Visual Analogue Scale (VAS) scores for back and leg pain were not significantly different between the ALIF and PLIF/TLIF groups. However, VAS back pain favoured ALIF over PLF at one year (n = 21, MD - 1.00, CI - 1.47, - 0.53), and at two years (2 studies, n = 67, MD - 1.39, CI - 1.67, - 1.11). The VAS leg pain scores (n = 46, MD 0.50, CI 0.12 to 0.88) at two years significantly favoured PLF. The Oswestry Disability Index (ODI) scores at one year were not significantly different between ALIF and the posterior approaches. At two years, ODI scores were also similar between the ALIF and the TLIF/PLIF. However, the ODI scores at two years (2 studies, n = 67, MD - 7.59, CI - 13.33, - 1.85) significantly favoured ALIF over PLF (I2 = 70%). The Japanese Orthopaedic Association Score (JOAS) for low back pain at one year (n = 21, MD - 0.50, CI - 0.78) and two years (two studies, n = 67, MD - 0.36, CI - 0.65, - 0.07) significantly favoured ALIF over PLF. No significant differences were found in leg pain at the 2-year follow-up. Adverse events displayed no significant differences between the ALIF and posterior approaches.

CONCLUSIONS

Stand-alone-ALIF demonstrated a shorter operative time and less blood loss than the PLIF/TLIF approach. Hospitalisation time is reduced with ALIF compared with TLIF. Patient-reported outcome measures were equivocal with PLIF or TLIF. VAS and JOAS, back pain, and ODI scores mainly favoured ALIF over PLF. Adverse events were equivocal between the ALIF and posterior fusion approaches.

Multilevel tandem spondylolisthesis associated with a reduced "safe zone" for a transpsoas lateral lumbar interbody fusion at L4-5

OBJECTIVE

The aim of this study was to investigate the effect of degenerative spondylolisthesis (DS) on psoas anatomy and the L4-5 safe zone during lateral lumbar interbody fusion (LLIF).

METHODS

In this retrospective, single-institution analysis, patients managed for low-back pain between 2016 and 2021 were identified. Inclusion criteria were adequate lumbar MR images and radiographs. Exclusion criteria were spine trauma, infection, metastases, transitional anatomy, or prior surgery. There were three age and sex propensity-matched cohorts: 1) controls without DS; 2) patients with single-level DS (SLDS); and 3) patients with multilevel, tandem DS (TDS). Axial T2-weighted MRI was used to measure the apical (ventral) and central positions of the psoas relative to the posterior tangent line at the L4-5 disc. Lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch were measured on lumbar radiographs. The primary outcomes were apical and central psoas positions at L4-5, which were calculated using stepwise multivariate linear regression including demographics, spinopelvic parameters, and degree of DS. Secondary outcomes were associations between single- and multilevel DS and spinopelvic parameters, which were calculated using one-way ANOVA with Bonferroni correction for between-group comparisons.

RESULTS

A total of 230 patients (92 without DS, 92 with SLDS, and 46 with TDS) were included. The mean age was 68.0 ± 8.9 years, and 185 patients (80.4%) were female. The mean BMI was 31.0 ± 7.1, and the mean age-adjusted Charlson Comorbidity Index (aCCI) was 4.2 ± 1.8. Age, BMI, sex, and aCCI were similar between the groups. Each increased grade of DS (no DS to SLDS to TDS) was associated with significantly increased PI (p < 0.05 for all relationships). PT, PI-LL mismatch, center psoas, and apical position were all significantly greater in the TDS group than in the no-DS and SLDS groups (p < 0.05). DS severity was independently associated with 2.4-mm (95% CI 1.1-3.8 mm) center and 2.6-mm (95% CI 1.2-3.9 mm) apical psoas anterior displacement per increased grade (increasing from no DS to SLDS to TDS).

CONCLUSIONS

TDS represents more severe sagittal malalignment (PI-LL mismatch), pelvic compensation (PT), and changes in the psoas major muscle compared with no DS, and SLDS and is a risk factor for lumbar plexus injury during L4-5 LLIF due to a smaller safe zone.

Preliminary evaluation of the efficacy of quantum molecular resonance coablative radiofrequency and microdiscectomy

Aims: The aim of this study was to determine whether there exists a difference in efficacy in the treatment of lumbar radiculopathy with quantum molecular resonance coablative radiofrequency, and quantum molecular resonance coablative radiofrequency and percutaneous microdiscectomy with grasper forceps (QMRG). Patients & methods: A total of 28 patients from La Fe University and Polytechnic Hospital in Valencia were enrolled in a retrospective cohort. Results: Treatment with QMRG significantly improved non-sleep-related and sleep-related outcome measures. At 6 months post-intervention, treatment with QMRG resulted in significantly better scores in numeric rating scale, Oswestry Disability Index, Short Form 12 Health Survey Physical and Total, Patient Global Impression of Improvement, sleep disturbance and the two sleep problems indexes. Conclusion: Treatment of lumbar radiculopathy with QMRG appears to be more effective at 6 months post-intervention.

Factors Affecting Stiffness-Related Functional Disability After Long Segmental Fusion for Adult Spinal Deformity

BACKGROUND

In general, stiffness-related functional disability (SRFD) is expected to increase as longer fusion length, but there have been no studies on factors affecting SRFD besides fusion length.

OBJECTIVE

To identify the factors affecting SRFD after long segmental fusion in patients with adult spinal deformity (ASD).

METHODS

We retrospectively reviewed the patients who underwent ≥4-segment fusion including sacrum for ASD. The severity of SRFD was evaluated using the Specific Functional Disability Index (SFDI) consisting of 12 items with 4 categories as follows: sitting on the floor, sanitation activity, lower body activity, and moving activity. Each category contains 3 items which was given a maximum of 4 points. The presumed factors affecting SFDI were analyzed.

RESULTS

A total of 148 patients were included in the study with their mean age of 67.3 years. The mean fusion length was 6.4 segments. The mean score of each SFDI category was highest in sitting on the floor (9.9), followed by lower body activities (7.6), sanitation activities (6.0), and moving activities (5.9). The total sum was 29.3 points. In multivariate analysis, total sum of SFDI was significantly higher in female sex, patients with higher American Society of Anesthesiology grade, and longer fusion length. However, the sagittal parameters did not show a significant correlation with SRFD, except pelvic incidence-lumbar lordosis which correlated with only one category (lower body activities).

CONCLUSION

This study showed that female sex, higher American Society of Anesthesiology grades, and longer fusion length influenced SRFD after long segmental fusion for ASD. Sagittal parameters related to the degree of deformity correction did not significantly affect SRFD.

Smoking Is Associated With Lower Satisfaction in Nondiabetic Patients Undergoing Minimally Invasive Single-level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This was a retrospective review of prospectively collected registry data.

OBJECTIVE

The objective of this study was to investigate the effect of smoking on 2 years postoperative functional outcomes, satisfaction, and radiologic fusion in nondiabetic patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) for degenerative spine conditions.

SUMMARY OF BACKGROUND DATA

There is conflicting data on the effect of smoking on long-term functional outcomes following lumbar fusion. Moreover, there remains a paucity of literature on the influence of smoking within the field of minimally invasive spine surgery.

METHODS

Prospectively collected registry data of nondiabetic patients who underwent primary single-level minimally invasive TLIF in a single institution was reviewed. Patients were stratified based on smoking history. All patients were assessed preoperatively and postoperatively using the Numerical Pain Rating Scale for back pain and leg pain, Oswestry Disability Index, Short-Form 36 Physical and Mental Component Scores. Satisfaction was assessed using the North American Spine Society questionnaire. Radiographic fusion rates were compared.

RESULTS

In total, 187 patients were included, of which 162 were nonsmokers, and 25 had a positive smoking history. In our multivariate analysis, smoking history was insignificant in predicting for minimal clinically important difference attainment rates in Physical Component Score and fusion grading outcomes. However, in terms of satisfaction score, positive smoking history remained a significant predictor (odds ratio=4.7, 95% confidence interval: 1.10-20.09, P=0.036).

CONCLUSIONS

Nondiabetic patients with a positive smoking history had lower satisfaction scores but comparable functional outcomes and radiologic fusion 2 years after single-level TLIF. Thorough preoperative counseling and smoking cessation advice may help to improve patient satisfaction following minimally invasive spine surgery.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

CURRENT RESULTS OF CONVENTIONAL LUMBAR ARTHRODESIS

ABSTRACT Objective: To evaluate the peri- and postoperative results and clinical repercussions in patients undergoing decompression surgery and single-level lumbar arthrodesis using the traditional technique (OTLIF) and to compare with the results of minimally invasive techniques (MITLIF) described in the literature. Methods: Our sample consisted of 22 patients who underwent TLIF surgery using the open technique (OTLIF) in the period October 2019 to January 2021, in our hospital. We compared the patients’ functional clinical results using the Oswestry scale in the preoperative period and 15 days after surgery, analyzed variables related to the perioperative period: surgery time, length of hospital stay, blood loss, use of a suction drain, and admission to the ICU, and compared these with the results reported in the literature for patients treated by the MITLIF technique. Results: The average age was 48.95 years and the most operated level was L4-L5 (55%). The average surgery time was 112.63 min. We did not use a suction drain in the postoperative period, there was no need for a blood transfusion in any patient, and no patient was admitted to the ICU. The average hospital stay was 1 day. Regarding the Oswestry Disability Index, the mean preoperative score was 44.73 and after 15 days, it was 24.05. Conclusions: surgical treatment using the OTLIF technique for single-level lumbar degenerative disease showed largely positive results, with improvement in disability scores, short hospital stay and low incidence of complications. When properly indicated, OTLIF is an excellent and safe option for the treatment of degenerative lumbar disease. Level of evidence IV; Case series study.

A biomechanical investigation of lumbar interbody fusion techniques

The anterior, posterior, transforaminal, and circumferential lumbar interbody fusions (ALIF, PLIF, TLIF, CLIF/360) are used to treat spondylolisthesis, trauma, and degenerative pathologies. This study aims to investigate the biomechanical effects of the lumbar interbody fusion techniques on the spine. A validated T12-sacrum lumbar spine finite-element model was used to simulate surgical fusion of L4-L5 segment using ALIF, PLIF with one and two cages, TLIF with unilateral and bilateral fixation, and CLIF/360. The models were simulated under pure-moment and combined (moment and compression) loadings to investigate the effect of different lumbar interbody fusion techniques on range of motion, forces transferred through the vertebral bodies, disc pressures, and endplate stresses. The range of motion of the lumbar spine was decreased the most for fusions with bilateral posterior instrumentations (TLIF, PLIF, and CLIF/360). The increase in forces transmitted through the vertebrae and increase in disc pressures were directly proportional to the range of motion. The discs superior to fusion were under higher pressure, which was attributed to adjacent segment degeneration in the superior discs. The increase in endplate stresses was directly proportional to the cross-sectional area and was greater in caudal endplates at the fusion level, which was attributed to cage subsidence. The response of the models was in line with overall clinical observations from the patients and can be further used for future studies, which aim to investigate the effect of geometrical and material variations in the spine. The model results will assist surgeons in making informed decisions when selecting fusion procedures based on biomechanical effects.

Improvement of coronal alignment in fractional low lumbar curves with the use of anterior interbody devices

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To determine if the addition of an anterior lumbar interbody fusion (ALIF) improves the fractional curve in adult spinal deformity correction when compared to posterior surgery alone. ALIF is commonly advocated to improve lordosis and fusion in adult deformity surgery. Improved fractional curve correction may help level the pelvis and minimize proximal malalignment.

METHODS

Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity were identified and stratified into patients who had an ALIF as part of their deformity correction procedure (ALIF + PSF), and those who had a posterior approach alone. The posterior approach (PSF) includes patients who had a posterolateral fusion with or without a transforaminal lumbar interbody fusion (TLIF). Radiographic parameters measured included pre-op and post-op fractional coronal curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence and sacral slope, major Cobb angle, coronal and sagittal SVA.

RESULTS

There were 31 cases in the ALIF + PSF group and 28 in the PSF group. Baseline demographic characteristics of the two groups were similar. Mean pre-op fractional coronal Cobb (18.3° vs 13.4°, p = 0.027) was larger in the ALIF + PSF group, whereas lumbar lordosis (31.0° vs 33.6°, p = 0.487) and pelvic parameters were similar between the two groups. Post-op lumbar lordosis was similar (48.2° vs 43.0°, p = 0.092). Greater fractional coronal curve correction was achieved in the ALIF + PSF group (67%) compared to the PSF group (36%) with a smaller post-op fractional coronal curve in the ALIF + PSF group (6.1°) compared to the PSF group (8.6°, p = 0.053).

CONCLUSION

There is a greater correction of the fractional curve in the ALIF + PSF group compared with the PSF group. While this may not be the primary indication for ALIF, it is a benefit which may facilitate overall deformity correction and leveling of the pelvis.

Rapid, midline retroperitoneal exposure for four-level anterior lumbar interbody fusion-technical case atlas

We describe a novel, rapid midline retroperitoneal operative technique in a patient, with multi-level degenerative scoliosis, who underwent an extensive L2-S1 anterior lumbar interbody fusion in addition to posterior instrumentation. Uniquely, our approach enables an essentially midline approach to the rectus muscle and uses the diminution of the transversalis fascia-to-peritoneum transition in the pelvis to provide expedited exposure—making it particularly helpful for ALIF exposure, retraction and intraoperative radiography. We minimize morbidity around the rectus sheath by dissecting only the medial rectus muscle and then gently, bluntly mobilizing the retroperitoneum from the deep pelvis cranially.

Comparison of outcomes between indirect decompression of oblique lumbar interbody fusion and MIS-TLIF in one single-level lumbar spondylosis

Minimal invasive spinal fusion has become popular in the last decade. Oblique lumbar interbody fusion (OLIF) is a relatively new surgical technique and could avoid back muscle stripping and posterior complex destruction as in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Between December 2016 and September 2018, patients with single level degenerative spondylosis were selected to enroll in this retrospective study. A total of 21 patients that underwent OLIF and 41 patients that received MIS-TLIF were enrolled. OLIF showed significantly less blood loss and shorter surgery time compared to MIS-TLIF (p < 0.05). The improvement in segmental lordosis and coronal balance was significantly more in OLIF group than MIS-TLIF group (p < 0.05). When comparing with MIS-TLIF, OLIF was significantly better in Oswestry Disability Index (ODI) and visual analogue scale for back pain improvement at post-operative 6 months (p < 0.05). Both OLIF and MIS-TLIF are becoming mainstream procedures for lumbar degenerative-related disease, especially for spondylolisthesis. However, the indirect decompression of OLIF has shown to have less perioperative blood loss and shorter surgery time than that of MIS-TLIF. In addition, OLIF gives superior outcome in restoring segmental lordosis and coronal imbalance. While both OLIF and MIS-TLIF provide optimal clinical outcomes, upon comparison between the two techniques, the indirect decompression of OLIF seems to be a superior option in modern days.

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial

Importance

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results.

Objective

To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year.

Design, Setting, and Participants

Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020.

Interventions

Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion.

Main Outcomes and Measures

The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score.

Results

Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%).

Conclusions and Relevance

Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach.

Trial Registration

ClinicalTrials.gov Identifier: NCT02076113.

Comparative Effectiveness of Expandable Versus Static Interbody Spacers via MIS LLIF: A 2-Year Radiographic and Clinical Outcomes Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study is to compare the radiographic and clinical outcomes of expandable interbody spacers to static interbody spacers.

METHODS

This is a retrospective, institutional review board-exempt chart review of 62 consecutive patients diagnosed with degenerative disc disease who underwent minimally invasive spine surgery lateral lumbar interbody fusion (MIS LLIF) using static or expandable spacers. There were 27 patients treated with static spacers, and 35 with expandable spacers. Radiographic and clinical functional outcomes were collected. Statistical results were significant if P < .05.

RESULTS

Mean improvement in visual analogue scale back and leg pain scores was significantly greater in the expandable group compared to the static group at 6 and 24 months by 42.3% and 63.8%, respectively (P < .05). Average improvement in Oswestry Disability Index scores was significantly greater in the expandable group than the static group at 3, 6, 12, and 24 months by 28%, 44%, 59%, 53%, and 89%, respectively (P < .05). For disc height, the mean improvement from baseline to 24 months was greater in the static group compared to the expandable group (P < .05). Implant subsidence was significantly greater in the static group (16.1%, 5/31 levels) compared with the expandable group (6.7%, 3/45 levels; P < .05).

CONCLUSIONS

This study showed positive clinical and radiographic outcomes for patients who underwent MIS LLIF with expandable spacers compared to those with static spacers. Sagittal correction and pain relief was achieved and maintained through 24-month follow-up. The expandable group had a lower subsidence rate than the static group.

Postoperative Loss of Lumbar Lordosis Affects Clinical Outcomes in Patients with Pseudoarthrosis after Posterior Lumbar Interbody Fusion Using Cortical Bone Trajectory Screw Fixation

Study Design

Retrospective cohort study.

Purpose

This study aimed to investigate relationships between clinical outcomes and radiographic parameters in patients with pseudoarthrosis after posterior lumbar interbody fusion (PLIF).

Overview of Literature

In some patients with pseudoarthrosis after PLIF, clinical symptoms improve following surgery, although pseudoarthrosis can often be one of the complications. However, there are no previous reports describing differences between patients with pseudoarthrosis after PLIF who have obtained better clinical outcomes and those who have not.

Methods

Twenty-seven patients who were diagnosed with pseudoarthrosis after single-level PLIF with cortical bone trajectory screw fixation (CBT-PLIF) were enrolled in this study. They were divided into two groups based on mean improvement of 22 points on the Oswestry Disability Index (ODI) at the 2-year follow-up. Group G consisted of 15 patients who showed improvement on the ODI of ≥22 points, and group P consisted of the residual 12 patients. Radiographic parameters, percentage of slip, lumbar lordosis (LL), segmental lordosis, segmental range of motion, screw loosening, and subsidence were compared between the two groups.

Results

There were no significant differences between the two groups on radiographic parameters except for postoperative changes in LL. Although surgery-induced changes in LL showed no significant difference between the two groups, changes in LL from before surgery to 2-year follow-up and during postoperative 2-year follow-up were significantly better in group G (mean change of LL: +3.5° and +5.1°, respectively) compared to group P (mean change of LL: −4.6° and −0.5°, respectively) (p<0.01 and 0.05, respectively).

Conclusions

Patients with greater improvement in ODI gained LL over the 2-year follow-up, whereas patients with less improvement in ODI lost LL during the 2-year follow-up. These results indicate that there is a significant correlation between clinical outcomes and LL even in patients with pseudoarthrosis after single-level CBT-PLIF.

Indirect decompression with lateral interbody fusion for severe degenerative lumbar spinal stenosis: minimum 1-year MRI follow-up

OBJECTIVE

The use of indirect decompression surgery for severe canal stenosis remains controversial. The purpose of this study was to investigate the efficacy of lateral interbody fusion (LIF) without posterior decompression in degenerative lumbar spinal spondylosis with severe stenosis on preoperative MRI.

METHODS

This is a retrospective case series from a single academic institution. The authors included 42 patients (45 surgical levels) who were preoperatively diagnosed with severe degenerative lumbar stenosis on MRI based on the previously published Schizas classification. These patients underwent LIF with supplemental pedicle screw fixation without posterior decompression. Surgical levels were limited to L3-4 and/or L4-5. All patients satisfied the minimum 1-year MRI follow-up. The authors compared the cross-sectional area (CSA) of the thecal sac and the clinical outcome scores (Japanese Orthopaedic Association [JOA] score) preoperatively, immediately postoperatively, and at the 1-year follow-up. Fusion status and disc height were evaluated based on CT scans obtained at the 1-year follow-up.

RESULTS

The CSA improved over time, increasing from 54.5 ± 19.2 mm2 preoperatively to 84.7 ± 31.8 mm2 at 3 weeks postoperatively and to 132.6 ± 37.5 mm2 at the last follow-up (average 28.3 months) (p < 0.001). The JOA score significantly improved over time (preoperatively 16.1 ± 4.1, 3 months postoperatively 24.4 ± 4.0, and 1-year follow-up 25.7 ± 2.9; p < 0.001). The fusion rate at the 1-year follow-up was 88.8%, and disc heights were significantly restored (preoperative, 6.3 mm and postoperative, 9.6 mm; p < 0.001). Patients showing poor CSA expansion (< 200% expansion rate) at the last follow-up had a higher prevalence of pseudarthrosis than patients with significant CSA expansion (> 200% expansion rate) (25.0% vs 3.4%, p < 0.001). No major perioperative complications were observed.

CONCLUSIONS

LIF with indirect decompression for degenerative lumbar disease with severe canal stenosis provided successful clinical outcomes, including restoration of disc height and indirect expansion of the thecal sac. Severe canal stenosis diagnosed on preoperative MRI itself is not a contraindication for indirect decompression surgery.

Perioperative adverse events after different fusion approaches for single-level lumbar spondylosis

Background

Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion).

Methods

Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts.

Results

In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events.

Conclusion

The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion.

Summary Sentence

Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.

Treatment with and without stabilizing lumbar spinal orthosis after one- or two-level spondylodesis: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Musculature affected during spondylodesis surgery may benefit and recover faster if supported by spine orthosis postoperatively.

METHODS

This prospective study included 50 consecutive patients undergoing one- or two-level spondylodesis. The intervention group received a lumbar spine orthosis (n= 23), while the control group remained without orthosis (n= 27). Patients were assessed for pain (Visual Analogue Scale, VAS), Oswestry Disability index (ODI) as well as the use of analgesics.

RESULTS

Patients wearing an orthosis postoperatively reported a higher degree of subjective stability. However, both intervention as well as control group did not show any significant differences for each of the follow-up points regarding VAS, ODI or the use of analgesics.

CONCLUSION

Wearing an orthosis has neither impact on subjective pain, the need for analgesics nor for postoperative functionality. However, patients reported that they profited from wearing the orthosis by feeling more stable, thereby nicely improving their postoperative mobility. Thus, novel patient reported outcome measures have to be developed to assess these features in future studies.

IMPROVEMENT OF ODI AND SF-36 QUESTIONNAIRES SCORE AFTER ONE YEAR OF PLIF OR TLIF

ABSTRACT Objective: Determine if patients undergoing PLIF or TLIF surgery achieved improvement in the score of ODI and SF-36 questionnaires one year after surgery. Methods: Retrospective, single-center and non-randomized study. Patients submitted to spinal surgery using the PLIF or TLIF technique were included who completed the ODI and SF-36 questionnaires at least at the preoperative visit, and one year after surgery. Patients were divided into two groups, Group 1 (1 surgery level) and Group 2 (> 1 surgery level) and the ODI and SF-36 scores were compared for improvement. Results: The mean age was 47 years, with 52% of males (13/25) and mean of 5 days of hospital stay. Patients presented a significant improvement of ODI questionnaire (p<0.001) and in all SF-36 domains except in General Health State (p=0.58). In each group, it was observed that patients submitted to more than one level of surgery had greater blood loss and shorter hospital stay; however, the improvement obtained in ODI and SF-36 compared to the one-level surgery group was similar. Conclusions: PLIF and TLIF techniques are effective and lead to improved scores in ODI and SF-36 questionnaires one year after surgery. Patients undergoing two or more levels of instrumentation showed significant and similar improvement in ODI and SF-36. Level of evidence II, Single-Center Retrospective Study.

Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5

OBJECTIVE Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4-5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4-5 level. METHODS The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months. RESULTS Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively. CONCLUSIONS This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4-5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4-5 disc space in patients with degenerative spondylolisthesis.

Value of single-level circumferential fusion: a 10-year prospective outcomes and cost-effectiveness analysis comparing posterior facet versus pedicle screw fixation

PURPOSE

To compare the clinical and economic outcomes of facet versus pedicle screw instrumentation for single-level circumferential lumbar spinal fusion.

METHODS

Outcomes included self-assessment of back and leg pain, pain drawing, ODI, pain medication usage, and procedure success. The CEA was based on the 10-year data collected, and the base-case was from a US payer perspective. Costs included the index surgery, additional surgeries, outpatient/ED visits, and medications. To determine quality-adjusted life years (QALYs), ODI scores were used to predict SF-6D utilities. Sensitivity analyses were performed from a modified payer perspective including device costs and from a societal perspective including productivity loss. Discounted and undiscounted incremental costs and QALYs were calculated. Bootstrapping was performed to estimate the distribution of incremental costs and effects.

RESULTS

Clinical improvement was significant from pre-op to 10-year follow-up for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet versus pedicle group at all follow-up periods > 1 year (p < 0.05). In the CEA base-case, facets had more QALYs (0.68) and lower costs (- $8650) per person compared with pedicle screws. Therefore, facets were dominant (i.e., provided cost savings and greater QALYs) compared with pedicle screws. Facets had a 97% probability of being below a willingness-to-pay threshold of $20,000 per QALY gained and were estimated to be dominant over pedicle screws in 84% of the simulations.

CONCLUSION

One-level circumferential spinal fusion using facet screws was clinically superior and provided cost savings compared with pedicle screw instrumentation in the USA.

Impact of surgery on pain, disability, and quality of life of patients with degenerative lumbar disease: Brazilian data

OBJECTIVE

To study the impact of surgery on pain, disability, quality of life, and patient satisfaction in a sample of patients with Degenerative Lumbar Disease (DLD).

METHODS

Retrospective analysis of prospectively collected data. Comparison between pre and postoperative (6 - 12 months) ODI and SF-36, plus postoperative Patient Satisfaction Index.

RESULTS

From a total of 216 patients included, improvement was observed in average scores of pain (201.2%), disability (39.7%), physical quality of life (42%), and mental quality of life (37.8%). Among these patients, 57.7% reached or surpassed the minimal clinically important difference (MCID) for ODI, 57.7% for the SF-36 pain component, 59.7% for the SF-36 physical component summary, and 50.5% achieved or surpassed the MCID for the SF-36 mental component summary.

CONCLUSIONS

Surgery produced a significantly positive impact on pain, disability, and quality of life of patients. Overall, 82.5% of the patients were satisfied.

Revision for Endoscopic Diskectomy: Is Lateral Lumbar Interbody Fusion an Option?

OBJECTIVE

This study aims to report the clinical outcome of stand-alone lateral lumbar interbody fusion (LLIF) on recurrent disk herniation and to compare the outcome of stand-alone LLIF to that of conventional transforaminal lumbar interbody fusion (TLIF).

METHODS

A retrospective study of 47 patients with recurrent disk herniation was included from January 2008 to October 2016. The inclusion criteria were 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous percutaneous endoscopic lumbar diskectomy surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, and 4) with follow-up more than 1 year. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey.

RESULTS

Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Radiographic analysis revealed a similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups. Two weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups. The TLIF group showed significantly larger postoperative VAS back pain after surgery (P = 0.03). For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups.

CONCLUSIONS

Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with recurrent disk herniation after a previous percutaneous endoscopic lumbar diskectomy surgery. Compared with the TLIF procedure, LLIF could achieve a similar improvement of patient-reported outcome with a better VAS back pain score.

Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

METHODS

All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

RESULTS

A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

CONCLUSIONS

We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

The Influence of Body Mass Index on Functional Outcomes, Satisfaction, and Return to Work After Single-level Minimally-invasive Transforaminal Lumbar Interbody Fusion: A Five-year Follow-up Study

STUDY DESIGN

Retrospective study using prospectively collected registry data.

OBJECTIVES

To evaluate the effect of obesity on patient-reported outcome measures of pain, disability, quality of life, satisfaction, and return to work after single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

SUMMARY OF BACKGROUND DATA

MIS-TLIF is an appealing alternative for obese patients with potentially lower complication risk. However, there is limited data investigating the influence of obesity on outcomes 5 years after MIS-TLIF.

METHODS

Prospectively collected registry data of 296 patients who underwent single-level MIS-TLIF at a single institution were reviewed. Patients had complete 2- and 5-year follow-up data. Patients were stratified into control (<25.0 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m) groups. Outcomes assessed were visual analogue scale for back pain, leg pain, Oswestry Disability Index, Short-form 36, North American Spine Society score for neurogenic symptoms, return to work (RTW), return to function (RTF), satisfaction, and expectation fulfilment. Length of operation, length of stay, and comorbidities were recorded.

RESULTS

Among the patients, 156 (52.7%) had normal weight, 108 (36.5%) were overweight, and 32 (10.8%) were obese. There was no difference in length of operation or hospitalization (P > 0.05). All three groups had comparable preoperative scores at baseline (P > 0.05). At 5 years, the control group had significantly higher PCS compared with the overweight (P = 0.043) and obese groups (P = 0.007), although the change in scores was similar (P > 0.05). The rate of MCID attainment, RTW, RTF, expectation fulfilment, and satisfaction was comparable.

CONCLUSION

Nonobese patients had better physical well-being in the mid-term, although obese patients experienced a comparable improvement in clinical scores. Obesity had no impact on patients' ability to RTW or RTF. Equivalent proportions of patients were satisfied and had their expectations fulfilled up to 5 years after MIS-TLIF.

LEVEL OF EVIDENCE

3.

Patient-reported outcomes unbiased by length of follow-up after lumbar degenerative spine surgery: Do we need 2 years of follow-up?

BACKGROUND

In modern clinical research, the accepted minimum follow-up for patient-reported outcome measures (PROMs) after lumbar spine surgery is 24 months, particularly after fusion. Recently, this minimum requirement has been called into question.

PURPOSE

We aim to quantify the concordance of 1- and 2-year PROMs to evaluate the importance of long-term follow-up after elective lumbar spine surgery.

STUDY DESIGN

Retrospective analysis of data from a prospective registry.

PATIENT SAMPLE

We identified all patients in our prospective institutional registry who underwent degenerative lumbar spine surgery with complete baseline, 12-month, and 24-month follow-up for ODI and numeric rating scales for back and leg pain (NRS-BP and NRS-LP).

OUTCOME MEASURES

Oswestry Disability Index (ODI) and NRS-BP and NRS-LP at 1 year and at 2 years.

METHODS

We evaluated concordance of 1- and 2-year change scores by means of Pearson's product-moment correlation and performed logistic regression to assess if achieving the minimum clinically important difference (MCID) at 12 months predicted 24-month MCID. Odds ratios (OR) and their 95% confidence intervals (CI), as well as model areas-under-the-curve were obtained.

RESULTS

A total of 210 patients were included. We observed excellent correlation among 12- and 24-month ODI (r = 0.88), NRS-LP (r = 0.76) and NRS-BP (r = 0.72, all p <.001). Equal results were obtained when stratifying for discectomy, decompression, or fusion. Patients achieving 12-month MCID were likely to achieve 24-month MCID for ODI (OR: 3.3, 95% CI: 2.4-4.1), NRS-LP (OR: 2.99, 95% CI: 2.2-4.2) and NRS-BP (OR: 3.4, 95% CI: 2.7-4.2, all p <.001) with excellent areas-under-the-curve values of 0.81, 0.77, and 0.84, respectively. Concordance rates between MCID at both follow-ups were 87.2%, 83.8%, and 84.2%. A post-hoc power analysis demonstrated sufficient statistical power.

CONCLUSIONS

Irrespective of the surgical procedure, 12-month PROMs for functional disability and pain severity accurately reflect those at 24 months. In support of previous literature, our results suggest that 12 months of follow-up may be sufficient for evaluating spinal patient care in clinical practice as well as in research.

Lumbar Interbody Fusions for Degenerative Spondylolisthesis: Review of Techniques, Indications, and Outcomes

STUDY DESIGN

Broad narrative review.

OBJECTIVES

To review and summarize the current literature on the outcomes, techniques, and indications of lumbar interbody fusion in degenerative spondylolisthesis.

METHODS

A thorough review of peer-reviewed literature was performed on the outcomes, techniques, and indications of lumbar interbody fusions in degenerative spondylolisthesis.

RESULTS

A number of studies have found similar results between interbody fusions and posterolateral fusion in the setting of degenerative spondylolisthesis. There is some evidence that suggests that interbody fusion may be a useful adjunct in the setting of unstable degenerative spondylolisthesis. The number of options for interbody fusions has quickly expanded. Initially, interbody fusions were accomplished via an anterior approach. Posterior and transforaminal interbody fusions are 2 options that accomplish an interbody fusion without the morbidity of an anterior approach. Over the past decade, minimally invasive options including extreme lateral, oblique, and minimally invasive transforaminal interbody fusions have gained popularity.

CONCLUSIONS

Lumbar interbody fusion can be a useful tool in the setting of unstable degenerative spondylolisthesis. A number of technique options, both open and minimally invasive, are available to accomplish an interbody fusion. The literature to this date does not support a clear benefit of one technique over others in the setting of degenerative spondylolisthesis.

Uninstrumented Posterior Lumbar Interbody Fusion: Have Technological Advances in Stabilizing the Lumbar Spine Truly Improved Outcomes?

BACKGROUND

Since the 1980s, numerous operations have replaced posterior lumbar interbody fusion (PLIF) with human bone. These operations often involve expensive implants and complex procedures. Escalating expenditures in lumbar fusion surgery warrant re-evaluation of classical PLIF with allogeneic ilium and without instrumentation. The purpose of this study was to determine the long-term fusion rate and clinical outcomes of PLIF with allogeneic bone (allo-PLIF).

METHODS

Between 1981 and 2006, 321 patients aged 12-80 years underwent 339 1-level or 2-level allo-PLIFs for degenerative instability and were followed for 1-28 years. Fusion status was determined by radiographs and as available, by computed tomography scans. Clinical outcome was assessed by the Economic/Functional Outcome Scale.

RESULTS

Of the 321 patients, 308 were followed postoperatively (average 6.7 years) and 297 (96%) fused. Fusion rates were lower for patients with substance abuse (89%, P = 0.007). Clinical outcomes in 87% of patients were excellent (52%) or good (35%). Economic/Functional Outcome Scale scores after initial allo-PLIF on average increased 5.2 points. Successful fusion correlated with nearly a 2-point gain in outcome score (P = 0.001). A positive association between a patient characteristic and outcome was observed only with age 65 years and greater, whereas negative associations in clinical outcomes were observed with mental illness, substance abuse, heavy stress to the low back, or industrial injuries. The total complication rate was 7%.

CONCLUSIONS

With 3 decades of follow-up, we found that successful clinical outcomes are highly correlated with solid fusion using only allogeneic iliac bone.

Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes

PURPOSE

Lumbar fusion for degenerative disorders is among the most common spine surgical procedures performed. The purpose of this study was to analyze fusion, complications, and clinical success for lumbar fusion performed with various surgical techniques as reported in the literature from 2000 to 2015 and compare with previous critical analysis of outcomes from 1980 to 2000.

METHODS

A systematic review of the literature to identify all studies of adult lumbar fusion for degenerative disorders published between January 1, 2000, and August 31, 2015, was performed adhering to PRISMA guidelines. Studies were included if they enabled analysis of outcomes of individual fusion techniques.

RESULTS

Data from 8599 patients extracted from 160 studies were recorded. Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) had significantly higher fusion rates compared to instrumented posterolateral fusion (PLF) (OR 3.20 and 2.46, respectively). Clinical success rate was statistically higher with MIS versus non-MIS fusion (OR 2.44). While methodological quality was higher in studies from 2000 to 2015 than prior decades, the outcomes of comparable procedures were about the same.

CONCLUSIONS

Lumbar fusions for degenerative disorders from 2000 to 2015 demonstrate a trend toward more interbody fusions and MIS techniques than prior decades. Clinical success with MIS appears more likely than with non-MIS fusions, despite equivalent fusion and complication rates. While these data are intriguing, they should be interpreted cautiously considering the level of heterogeneity of the studies available. Further, high-quality comparative studies are warranted to better understand the relative benefits of more complex interbody and MIS fusions for these conditions. These slides can be retrieved under Electronic Supplementary Material.

[Minimally invasive extraforaminal lumbar interbody fusion]

OBJECTIVES

The objective of the present study was to determine the indications, surgical technique, results, and complications of minimally invasive extraforaminal lumbar interbody fusion (ELIF).

INTRODUCTION

ELIF is characterized as removal of the superior articular process (SAP) to access the intra-canalicular root and disc through Kambin's triangle.

METHODS

A retrospective study was conducted of 40 patients operated upon between 2013 and 2015. Patients with low back pain or root pain due to degenerative disc disease, spondylolisthesis grade 1 and 2, recurrent disc herniation, and recess-foraminal stenosis were included. A visual analogue scale (VAS), the Oswestry index, the Weiner scale and the modified MacNab criteria were used to assess pain, clinical and functional results and patient satisfaction one year after surgery. Complications were documented and rated according to their severity, in four degrees.

RESULTS

We operated on 25 women and 15 men of average age 57 years. Of the forty, 47.5% were treated for spondylolisthesis, 25% by recess foraminal stenosis. In total, 54 interbody cages and 188 percutaneous pedicle screws were placed; and the mean duration of surgery was 245 (±25.4) minutes. The mean hospitalization time was 3.5 (±0.49) days. We observed nine Grade 1 and one Grade 2 complication. The mean preoperative ODI score was 51.9 ± 4.96, which improved to 12.2 ± 3.19 at one year (P < 0.0001). The mean VAS low back pain rating improved from 8.81 ± 0.62 to 2.12 ± 0.89 (P < 0.0001). By one year post-operatively, 77.5% of the patients had fusion (Bridwell grade 1 or 2).

CONCLUSIONS

ELIF is a safe and effective surgical approach. Satisfactory clinical outcomes, comparable to traditional techniques, can be achieved with facet resection limited to the superior articular process.

Factors associated with patient satisfaction for PLIF: Patient satisfaction analysis

Introduction: Posterior lumbar interbody fusion (PLIF) has produced satisfactory clinical outcomes; however, all previous reports have only included evaluations by surgeon-based methods. The purpose of this study was to investigate patient-based surgical outcomes and the factors associated with patient satisfaction for PLIF. Methods: Patients who underwent PLIF for lumbar spondylolisthesis were reviewed (n=443). The average follow-up period was 8 years. Surgical outcomes were assessed using an original questionnaire, a numerical rating scale (NRS), the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association (JOA) score, and the recovery rate. The original questionnaire consisted of five categories, with patient-evaluated score out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery on a 5-point scale. According to the questionnaire responses, patient-based outcomes were divided into three groups: positive, intermediate, and negative and were compared with the NRS, SF-36, and JOA scores. Furthermore, factors associated with patient satisfaction were examined. Results: A total of 273 patients responded. Response rate was 62%. The average patient-evaluated score for surgery was 82 points. In terms of satisfaction section, positive, intermediate, and negative response rates were 82%, 7%, and 11%, respectively. With respect to other sections, positive, intermediate, and negative response rates were 87%, 7%, and 6% in improvement section; 66%, 23%, and 11% in recommending section; and 72%, 18%, and 10% in repeat section, respectively. The average pre- and postoperative JOA scores were 12 and 24, respectively. Significant correlations were detected between patient-based surgical outcomes and the NRS scores, physical component scores of the SF-36, and the JOA score. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response. Conclusions: High satisfaction rate to PLIF and significant correlation between patient- and surgeon-based surgical outcomes were detected. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response.

Factors affecting health-related quality of life one year after lumbar spinal fusion

OBJECTIVE

To identify preoperative factors that affect the medical outcome study 36-item short form health survey (SF-36) score 1 year after lumbar spinal fusion.

METHODS

Participants were selected from among 624 patients who underwent lumbar spinal fusion between April 1, 2009 and March 31, 2011 who were followed up for 1 year or more. The SF-36 version 2 was used to evaluate HRQOL. The following preoperative parameters were investigated: sex, age, body mass index (BMI), employment status (other than home-making), living with other family members, smoking, orthopedic disorder in another part of the body (other than lumbar spinal disease), history of lumbar spinal surgery, bladder function, and leg muscle strength.

RESULTS

94 patients were included. None of the independent preoperative factors exhibited a high degree of correlation, and the absence of multicollinearity was confirmed before further analysis was performed. The first canonical variates were age and leg muscle strength, which had a major effect on physical functioning, role physical, and role emotional 1 year after surgery, and the second canonical variates were employment status, sex, and orthopedic disorder in another part of the body, which had a major effect on general health 1 year after surgery.

CONCLUSIONS

The SF-36 score 1 year after lumbar spinal fusion was affected by the preoperative factors of age, leg muscle strength, living with other family members, employment status, sex, and orthopedic disorders in another part of the body.

Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation: A Retrospective Study With 2-year Follow-up

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to evaluate the clinical and radiological outcomes of mini-open ALIF (MO-ALIF) with self-anchored stand-alone cages for the treatment of lumbar disc herniation in comparison with transforaminal lumbar interbody fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

METHODS

This study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n = 42) or TLIF (n = 40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

RESULTS

Patients who underwent TLIF had a significantly higher volume of blood loss (295.2 ± 81.4 vs. 57.0 ± 15.2 mL) and longer surgery time (130.7 ± 45.1 vs. 60.4 ± 20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group.

CONCLUSION

MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

LEVEL OF EVIDENCE

3.

Correlations Between the SF-36, the Oswestry-Disability Index and Rolland-Morris Disability Questionnaire in Patients Undergoing Lumbar Decompression According to Types of Spine Origin Pain

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To determine the correlation between SF-36 (a measure for overall health status in patients) and Oswestry-Disability Index (ODI) or Rolland-Morris Disability Questionnaire (RMDQ) confined to spine according to the type of pain from the spine.

SUMMARY OF BACKGROUND DATA

Data showed moderate correlation between ODI and SF-36 Physical Component Score (PCS), Physical Functioning (PF) (r=-0.46), Physical Role Functioning (RP) (r=-0.284), Bodily Pain (BP) (r=-0.327), and Mental Component Score (MCS), Emotional Role Functioning (r=-0.250), Social Role Functioning (r=0.254), Vitality (r=0.296).

MATERIALS AND METHODS

Between January 1, 2008 and December 31, 2013, a total of 69 patients were enrolled in this study. They were diagnosed with lumbar spinal stenosis and underwent decompression surgery such as laminotomy in this hospital. The 3 standardized questionnaires (ODI, RMDQ, and SF-36) were given to these patients, at least 1 year after the surgery.

RESULTS

ODI and SF-36 had a statistically significant (P=0.001) and moderate correlation. Small correlations were also seen between Physical Functioning (r=-0.46), Physical Role Functioning (r=-0.284), and Bodily Pain (r=-0.327) of SF-36 PCS and ODI, and between Emotional Role Functioning (r=-0.250), Social Role Functioning (r=-0.254), and Vitality (r=-0.296) of SF-36 Mental Component Score and ODI. Items in ODI for the level of pain while standing and traveling were mostly related to axial back pain, while item of lifting was related to referred buttock pain. Sleeping disturbance section in the ODI was mainly caused by radiated leg pain. In addition, RMDQ was also associated to the 3 types of pain.

CONCLUSIONS

Moderate correlation was found between ODI or RMDQ as a condition-specific outcome and the SF-36, indicating overall health status. ODI was found to be a more adequate measure to evaluate axial back pain rather than referred pain or radiating pain. RMDQ was adequate to measure the health status and to evaluate the 3 types of spine pain. These 3 instruments could therefore provide the clinician with complementary information about the patient's status.

Why Lumbar Artificial Disk Replacements (LADRs) Fail

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

To determine why artificial disk replacements (ADRs) fail by examining results of 91 patients in FDA studies performed at a single investigational device exemption (IDE) site with minimum 2-year follow-up.

SUMMARY OF BACKGROUND DATA

Patients following lumbar ADR generally achieve their 24-month follow-up results at 3 months postoperatively.

MATERIALS AND METHODS

Every patient undergoing ADR at 1 IDE site by 2 surgeons was evaluated for clinical success. Failure was defined as <50% improvement in ODI and VAS or any additional surgery at index or adjacent spine motion segment. Three ADRs were evaluated: Maverick, 25 patients; Charité, 31 patients; and Kineflex, 35 patients. All procedures were 1-level operations performed at L4-L5 or L5-S1. Demographics and inclusion/exclusion criteria were similar and will be discussed.

RESULTS

Overall clinical failure occurred in 26% (24 of 91 patients) at 2-year follow-up. Clinical failure occurred in: 28% (Maverick) (7 of 25 patients), 39% (Charité) (12 of 31 patients), and 14% (Kineflex) (5 of 35 patients). Causes of failure included facet pathology, 50% of failure patients (12 of 24). Implant complications occurred in 5% of total patients and 21% of failure patients (5 of 24). Only 5 patients went from a success to failure after 3 months. Only 1 patient went from a failure to success after a facet rhizotomy 1 year after ADR.

CONCLUSIONS

Seventy-four percent of patients after ADR met strict clinical success after 2-year follow-up. The clinical success versus failure rate did not change from their 3-month follow-up in 85 of the 91 patients (93%). Overall clinical success may be improved most by patient selection and implant type.

Prognostic Factors for Satisfaction After Decompression Surgery for Lumbar Spinal Stenosis

BACKGROUND

Surgical treatment for lumbar spinal stenosis is associated with both short- and long-term benefits with improvements in patient function and pain. Even though most patients are satisfied postoperatively, some studies report that up to one-third of patients are dissatisfied.

OBJECTIVE

To present clinical outcome data and identify prognostic factors related to patient satisfaction 1 yr after posterior decompression surgery for lumbar spinal stenosis.

METHODS

This multicenter register study included 2562 patients. Patients were treated with various types of posterior decompression. Patients with previous spine surgery or concomitant fusion were excluded. Patient satisfaction was analyzed for associations with age, sex, body mass index, smoking status, duration of pain, number of decompressed vertebral levels, comorbidities, and patient-reported outcome measures, which were used to quantify the effect of the surgical intervention.

RESULTS

At 1-yr follow-up, 62.4% of patients were satisfied but 15.1% reported dissatisfaction. The satisfied patients showed significantly greater improvement in all outcome measures compared to the dissatisfied patients. The outcome scores for the dissatisfied patients were relatively unchanged or worse compared to baseline. Association was seen between dissatisfaction, duration of leg pain, smoking status, and patient comorbidities. Patients with good walking capacity at baseline were less prone to be dissatisfied compared to patients with poor walking capacity.

CONCLUSION

This study found smoking, long duration of leg pain, and cancerous and neurological disease to be associated with patient dissatisfaction, whereas good walking capacity at baseline was positively associated with satisfaction after 1 yr.

Evaluating Outcomes of Stand-Alone Anterior Lumbar Interbody Fusion: A Systematic Review

BACKGROUND

Stand-alone anterior lumbar interbody fusion (ALIF) is an effective surgical approach for selected spinal pathologies. It avoids the morbidity and complications associated with instrumented ALIF, such as plate fixation and the traditionally used posterior approach. Despite improved disc space visualization and clearance, the associated posterior instability and increased risk of nonfusion present major challenges to this approach. The integral cage design aims to address these challenges by providing the necessary stabilization through intracorporeal screws. However, there is limited and controversial data available for stand-alone ALIF and integral cage fixation. To our knowledge, this is the first systematic review to evaluate recent findings on outcomes of stand-alone ALIF devices to explore areas of controversy and identify directions for future research.

METHODS

Two reviewers conducted independent, systematic literature searches for appropriate studies in 5 electronic databases as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were filtered by the use of specified selection criteria, particularly exclusion of studies with supplementary fixation to ALIF and studies published before the year 2000. A total of 17 studies met the criteria, and their data were comprehensively extracted and analyzed.

RESULTS

The current literature is supportive of stand-alone ALIF due to acceptable clinical outcomes, promising fusion rates and disc height restoration. However, data and outcomes remain preliminary, and there are numerous areas of controversy.

CONCLUSIONS

There is evidence for the efficacy and safety of stand-alone ALIF. However, the extent of improvement based on specific indications for surgery remains unclear. Further investigation utilizing more methodologically rigorous studies of long-term outcomes is necessary to address these issues.

Navigation and Image Injection for Control of Bone Removal and Osteotomy Planes in Spine Surgery

BACKGROUND AND IMPORTANCE: In contrast to cranial interventions, neuronavigation in spinal surgery is used in few applications, not tapping into its full technological potential. We have developed a method to preoperatively create virtual resection planes and volumes for spinal osteotomies and export 3-D operation plans to a navigation system controlling intraoperative visualization using a surgical microscope's head-up display. The method was developed using a Sawbone® model of the lumbar spine, demonstrating feasibility with high precision. Computer tomographic and magnetic resonance image data were imported into Amira®, a 3-D visualization software. Resection planes were positioned, and resection volumes representing intraoperative bone removal were defined. Fused to the original Digital Imaging and Communications in Medicine data, the osteotomy planes were exported to the cranial version of a Brainlab® navigation system. A navigated surgical microscope with video connection to the navigation system allowed intraoperative image injection to visualize the preplanned resection planes.

CLINICAL PRESENTATION: The workflow was applied to a patient presenting with a congenital hemivertebra of the thoracolumbar spine. Dorsal instrumentation with pedicle screws and rods was followed by resection of the deformed vertebra guided by the in-view image injection of the preplanned resection planes into the optical path of a surgical microscope. Postoperatively, the patient showed no neurological deficits, and the spine was found to be restored in near physiological posture.

CONCLUSION: The intraoperative visualization of resection planes in a microscope's head-up display was found to assist the surgeon during the resection of a complex-shaped bone wedge and may help to further increase accuracy and patient safety.

Stand-alone anterior lumbar interbody fusion: indications, techniques, surgical outcomes and complications

INTRODUCTION

Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.

The Negligible Influence of Chronic Obesity on Hospitalization, Clinical Status, and Complications in Elective Posterior Lumbar Interbody Fusion

Background. Posterior lumbar interbody fusion (PLIF) is a common surgical treatment for degenerative spinal instability, but many surgeons consider obesity a contraindication for elective spinal fusion. The aim of this study was to analyze whether obesity has any influence on hospitalization parameters, change in clinical status, or complications. Methods. In this prospective study, regression analysis was used to analyze the influence of the body mass index (BMI) on operating time, postoperative care, hospitalization time, type of postdischarge care, change in paresis or sensory deficits, pain level, wound complications, cerebrospinal fluid leakage, and implant complications. Results. Operating time increased only 2.5 minutes for each increase of BMI by 1. The probability of having a wound complication increased statistically with rising BMI. Nonetheless, BMI accounted for very little of the variation in the data, meaning that other factors or random chances play a much larger role. Conclusions. Obesity has to be considered a risk factor for wound complications in patients undergoing elective PLIF for degenerative instability. However, BMI showed no significant influence on other kinds of peri- or postoperative complications, nor clinical outcomes. So obesity cannot be considered a contraindication for elective PLIF.

Transsacral transdiscal L5-S1 screws for the management of high-grade spondylolisthesis in an adolescent

The surgical management of high-grade spondylolisthesis in adolescents remains a controversial issue. Because the basic procedure, posterolateral fusion, is associated with a significant rate of pseudarthrosis and listhesis progression, there is a pressing need for alternative surgical techniques. In the present report, the authors describe the case of an adolescent patient with significant low-back pain who was found to have Grade IV spondylolisthesis at L5-S1 that was treated with transsacral transdiscal screw fixation. Bilateral pedicle screws were placed starting from the top of the S-1 pedicle, across the L5-S1 intervertebral disc space, and into the L-5 body. At 14 months after surgery, the patient had considerable improvement in his pain and radiographic fusion across L5-S1. The authors conclude that transsacral transdiscal pedicle screws may serve as an efficacious and safe option for the correction of high-grade spondylolisthesis in adolescent patients.

Effects of Lumbar Stiffness After Lumbar Fusion Surgery on Activities of Daily Living

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to assess the effects of lumbar stiffness after lumbar fusion surgery on functional limitations, health-related quality of life, and activities of daily living (ADL).

SUMMARY OF BACKGROUND DATA

Postoperative outcomes after fusion surgery are usually assessed using patient-reported instruments to describe disability related to pain and health status. There are few studies on the effects of lumbar stiffness on ADL after lumbar fusion surgery.

METHODS

This study included 93 patients who underwent lumbar fusion surgery for degenerative lumbar disease. Their mean age was 69 years (range 51-79), and the mean follow-up was 34 months (24-46). The patients were categorized into 5 groups according to the number of segments involved: 0 level (decompression), 1 level, 2 levels, 3 levels, and 4 levels. They completed a 21-item questionnaire about their ADL and the Short Form Health Survey 36 (SF-36) to evaluate the effects of lumbar stiffness on ADL after surgery.

RESULTS

There was a linear trend toward a decreased rating in all items in our questionnaire and in the physical component summary in the SF-36 related to postoperative lumbar stiffness. These trends were significantly related to the number of fused segments (P < 0.05 and P < 0.001, respectively). Patient satisfaction did not differ between the groups (P = 0.381). Patients who received a 1- or 2-level fusion reported no serious limitations in most ADL. Patients who received a 3- or 4-level fusion, especially 4-level fusion, reported more limitations because of postoperative lumbar stiffness.

CONCLUSION

This study investigated in detail the effects of lumbar stiffness after fusion surgery on ADL. Spine surgeons should consider the patient's occupation and lifestyle in preoperative planning. These results will help the surgeon explain the possible outcomes to patients planning to undergo fusion surgery.

LEVEL OF EVIDENCE

2.

Patient-Based Surgical Outcomes of Posterior Lumbar Interbody Fusion: Patient Satisfaction Analysis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The purpose of this study was to investigate: (1) patient-based surgical outcomes of posterior lumbar interbody fusion (PLIF); (2) correlations between patient-based surgical outcomes and surgeon-based surgical outcomes; (3) factors associated with patient satisfaction.

SUMMARY OF BACKGROUND DATA

There have been no reports of patient-based surgical outcomes of PLIF for lumbar spondylolisthesis.

METHODS

Patients who underwent PLIF for L4 degenerative spondylolisthesis between 2006 and 2009 were reviewed (n = 121). Surgical outcomes were assessed 5 years after primary surgery using a questionnaire, a numerical rating scale (NRS) of pain, the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association score (JOA score), and the recovery rate. The original questionnaire consisted of 5 categories, with scoring out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery. Patient-based outcomes were divided into 3 groups according to the questionnaire responses as positive, intermediate, and negative and were compared with the JOA scores.

RESULTS

A total of 103 patients responded, for a response rate of 85%. The average patient-evaluated score for surgery was 82 points. The positive response rate in each category was 78% for satisfaction, 88% for improvement, 74% for recommendation, and 71% for repeat. The average pre- and postoperative JOA scores were 11.2 and 23.2, respectively. The average recovery rate was 68.5%. There were significant correlations between patient-based surgical outcomes and the JOA score. Furthermore, there were significant correlations between patient-based surgical outcomes and the NRS and physical component scores of the SF-36. Postoperative permanent motor loss was a major factor related to a negative response.

CONCLUSION

The patient-evaluated score for surgery was 82 points. More than 70% of patients gave positive responses in all sections of the questionnaire. There were significant correlations between patient-based and surgeon-based surgical outcomes.

LEVEL OF EVIDENCE

2.