Indirect effects of decompression surgery on glycemic homeostasis in patients with type 2 diabetes mellitus and lumbar spinal stenosis

Influence of Handgrip Strength and Paraspinal Muscles' Volume on Clinical Outcomes in the Patients With Each Sagittal Imbalance and Lumbar Spinal Stenosis

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To compare handgrip strength (HGS), paraspinal muscles' (PSM) volume, and their effects on clinical symptom severity between the patients with sagittal imbalance (SI) and symptomatic lumbar spinal stenosis (LSS).

METHODS

A total of 54 paired consecutive patients with SI and LSS were enrolled after propensity score matching. Preoperative HGS, cross-sectional area (CSA) of psoas (PS) and multifidus (MF) muscles, and patient-reported measures, including visual analog scale (VAS) for back/ leg pain, Oswestry Disability Index (ODI), and EuroQOL (EQ-5D) were compared between both groups. Within each SI and LSS group, patient-reported measures were compared between high and low HGS subgroups. The correlation of HGS and CSA of PSMs to patient-reported measures was evaluated.

RESULTS

There was no difference in HGS between 2 groups, however, the CSA of PS and MF muscles in SI group was significantly lower than those in LSS group. Patients with low HGS showed inferior results for ODI and EQ-5D, compared to those with high HGS subgroup in both SI and LSS groups. HGS and CSA of MF muscle were correlated with ODI in both groups.

CONCLUSIONS

There was no significant difference between the SI and LSS groups in HGS, however, PSMs' volume in SI group were significantly lower than those in LSS group. Therefore SI would be associated with loss of localized muscle mass in back area, rather than global skeletal muscle weakness. HGS and PSMs' volume were adversely associated with functional status in SI and LSS patients.

Ligament Alteration in Diabetes Mellitus

Connective tissue ageing is accelerated by the progressive accumulation of advanced glycation end products (AGEs). The formation of AGEs is characteristic for diabetes mellitus (DM) progression and affects only specific proteins with relatively long half-lives. This is the case of fibrillar collagens that are highly susceptible to glycation. While collagen provides a framework for plenty of organs, the local homeostasis of specific tissues is indirectly affected by glycation. Among the many age- and diabetes-related morphological changes affecting human connective tissues, there is concurrently reduced healing capacity, flexibility, and quality among ligaments, tendons, bones, and skin. Although DM provokes a wide range of known clinical disorders, the exact mechanisms of connective tissue alteration are still being investigated. Most of them rely on animal models in order to conclude the patterns of damage. Further research and more well-designed large-cohort studies need to be conducted in order to answer the issue concerning the involvement of ligaments in diabetes-related complications. In the following manuscript, we present the results from experiments discovering specific molecules that are engaged in the degenerative process of connective tissue alteration. This review is intended to provide the report and sum up the investigations described in the literature concerning the topic of ligament alteration in DM, which, even though significantly decreasing the quality of life, do not play a major role in research.

Trends in Weight and Body Mass Index after Spinal Surgery for Degenerative Disease

BACKGROUND

Currently, 37% of adults in the United States are obese, and 34% are overweight. Obesity poses a particularly complex challenge in spinal surgery management, whereby risk of adverse surgical outcomes increases with increased body mass index (BMI). When patients are counseled to reduce weight to levels associated with acceptable surgical risks, patients often respond that their spinal problems prohibit the exercise needed to lose the required weight and counter that surgery will allow for increased activity and thereby facilitate weight loss. A retrospective study of a US Veterans Affairs (USVA) nationwide patient database was undertaken.

METHODS

A request was made of the USVA Corporate Data Warehouse for data on all patients undergoing elective spine surgery for degenerative conditions over a 10-year period.

RESULTS

The mean preoperative age of 65 667 patients identified was 59 years. The mean preoperative weight was 91.8 kg, and BMI was 29.2. Before surgery, 26 772 patients had a BMI of >30. After surgery, 12 564 (46.9%) lost at least 2.3 kg, 9450 (35.3%) gained at least 2.3 kg, and 4758 (17.8%) were unchanged. After surgery, 4853 (18.1%) lost at least 11.3 kg and 1360 (5.1%) lost at least 22.7 kg. At a mean of 1.9 years after index surgery, mean postoperative weight was 92.5 kg, and BMI was 29.4. Of the 65 667 patients, 23 125 (35.2%) patients lost at least 2.3 kg, 27 571 (42.0%) gained at least 2.3 kg, and 14 971 (23.0%) remained within 2.3 kg of their preoperative weight.

CONCLUSION

The study results will aid in counseling patients regarding realistic expectations about weight loss after spinal surgery.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

This evidence will allow for realistic patient counseling regarding the likelihood of weight loss after elective spinal surgery.

The influence of hand grip strength on surgical outcomes after surgery for degenerative lumbar spinal stenosis: a preliminary result

BACKGROUND CONTEXT

Although a number of prognostic factors have been demonstrated to be associated with surgical outcome of degenerative lumbar spinal stenosis (DLSS), no study has investigated the relation between hand grip strength (HGS) and treatment outcome of DLSS.

PURPOSE

The purpose of the present study was to examine the influence of HGS on surgical outcomes after surgery for patients with DLSS.

STUDY DESIGN

This is an observational study.

PATIENT SAMPLE

Patients who underwent spine surgery for DLSS were included in the study.

OUTCOME MEASURES

Oswestry Disability Index (ODI), EuroQOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain were assessed.

MATERIALS AND METHODS

A total of 172 consecutive patients who underwent spine surgery for DLSS were included in the present study. Patients were assigned to either high HGS group (≥26 kg for men and ≥18 kg for women, n=124) or low HGS group (<26 kg for men and <18 kg for women, n=48) based on their preoperative HGS performance. Oswestry Disability Index, EQ-5D, and VAS scores for back and leg pain were assessed and compared between two groups preoperatively, 3 and 6 months after surgery. The primary outcome measure was baseline-adjusted ODI scores 6 months after surgery. The secondary outcome measures, including the overall ODI score, EQ-5D score, VAS score for back and leg pain, were assessed at each time point during the 6-month follow-up period.

RESULTS

As primary outcome, baseline-adjusted ODI scores were significantly lower in the high HGS group than in the low HGS group 6 months after surgery. In the secondary outcome measurements, the ODI, EQ-5D, and VAS scores for back and leg pain improved significantly with time after surgery in both groups. The effects of HGS group on the overall changes in the ODI and EQ-5D scores during the 6-month period were significantly different between the two groups; however, they were not significantly different on VAS score for back and leg pain. The pattern of change in the ODI during the follow-up period was significantly different between the two groups.

CONCLUSIONS

Patients with preoperative high HGS display better surgical outcome in terms of disability and health status 6 months after spine surgery. Preoperative HGS can act as a predictor of surgical outcome in patients with DLSS.

Change in pain catastrophizing in patients with lumbar spinal surgery

BACKGROUND CONTEXT

Even though catastrophizing can negatively moderate the outcome of surgery for lumbar spinal stenosis (LSS), it is still unclear whether pain catastrophizing is an enduring stable or a dynamic structure related to pain intensity after spine surgery.

PURPOSE

The purpose of this study was to determine whether catastrophizing would change in patients who undergo spinal surgery for LSS.

STUDY DESIGN

A prospective observational cohort study was carried out.

STUDY SAMPLE

Patients who underwent spine surgery for LSS comprised the study sample.

OUTCOME MEASURES

The Visual Analog Pain Scale (VAS) scores for back/leg pain, Oswestry Disability Index (ODI), and Pain Catastrophizing Scale (PCS) were the outcome measures.

METHODS

The present observational cohort consisted of 138 patients between the ages of 40 and 80 years who were scheduled to undergo surgery for LSS. Among them, a total of 96 patients underwent a 3-year assessment after surgery. The PCS questionnaire was used for pain catastrophizing assessment before and 3 years after surgery. The VAS for back and leg pain, and ODI were assessed 3 and 6 months, and 1 and 3 years after surgery. The correlations between variables were analyzed before and 3 years after surgery. To clarify the causal relationship, time-series and linear mixed models were also used.

RESULTS

At 3 years after surgery, ODI, VAS for back and leg pain, and PCS scores were significantly decreased. The correlation of PCS with VAS and ODI was significant both before and 3 years after surgery. The correlation between change in pain or disability and change in pain catastrophizing from preoperative to 3 years after surgery was also significant. In the causal relationship between pain and catastrophizing, overall changes in pain and disability were significant predictors of overall changes in pain catastrophizing from baseline to 3 year after surgery.

CONCLUSION

The present study shows that pain catastrophizing can change in association with the improvement in pain intensity after spine surgery. Therefore, catastrophizing may not be an enduring stable construct, but a dynamic construct.

Do Obese and Extremely Obese Patients Lose Weight After Lumbar Spine Fusions? Analysis of a Cohort of 7303 Patients from the Kaiser National Spine Registry

MINI: The outcome of interest was ≥ 5% weight change 1 year postoperative from baseline. Seven thousand three hundred three lumbar fusions in the Kaiser Permanente Spine Registry between 2009 and 2013 were analyzed. Weight loss occurred in: body mass index < 30, 11.1%; obese, BMI 30 to 39, 16.6%, odds ratio = 1.42; extremely obese, body mass index ≥40, 21.1%, odds ratio = 1.73.

STUDY DESIGN

A retrospective cohort study from the Kaiser Permanente Spine Registry.

OBJECTIVE

The aim of this study was to determine whether obese and extremely obese patients with lumbar spine fusions lost a clinically significant amount of weight (≥5%) 1 year after their surgery.

SUMMARY OF BACKGROUND DATA

Obesity in the United States has a prevalence of 35% and is a global health issue. Obesity is associated with lumbar spine disease. There is limited evidence regarding postsurgical weight loss after spine surgery.

METHODS

Adult patients in the Kaiser Permanente Spine Registry with lumbar fusions performed between 2009 and 2013 were included in the study sample (n = 7303). The outcome of interest was ≥5% weight change 1 year postoperative from baseline. Three body mass index (BMI) groups were analyzed (BMI < 30; 30-39 obese; ≥40 extremely obese). Covariate analysis, multivariable logistic regression, odds ratios (ORs), and 95% confidence intervals (95% CIs) are provided.

RESULTS

At the time of spine surgery, 4456 (61%) had a BMI < 30, 2519 (34.5%) had a BMI between 30 and 39, 232 (3.2%) had a BMI ≥40, and 96 (1.3%) were missing their intraoperative BMI. We observed the following weight loss pattern: BMI < 30, 11.1%; BMI 30 to 39, 16.6%; BMI ≥40, 21.1%. We observed the following weight gain pattern: BMI < 30, 15.6%; BMI 30 to 39, 12.7%; BMI ≥40, 9.5%. After risk-adjustment, obese and extremely obese patients were more likely to lose a clinically significant amount of weight 1 year after surgery (BMI 30-39: OR = 1.42, 95% CI 1.22-1.65; BMI ≥40: OR = 1.73, 95% CI 1.21-2.47) compared with nonobese patients.

CONCLUSION

In this large cohort of patients with lumbar spinal fusions, we observed more significant weight loss in obese and extremely obese patients than nonobese patients. Additional research is needed to determine whether this weight loss is due to improvements in back pain and increased physical activity.

LEVEL OF EVIDENCE

3.

Diabetes mellitus is associated with increased elastin fiber loss in ligamentum flavum of patients with lumbar spinal canal stenosis: results of a pilot histological study

PURPOSE

Lumbar spinal canal stenosis (LSCS) is associated with fibrosis, decreased elastin-to-collagen ratio, and hypertrophy of the ligamentum flavum (LF). Diabetes mellitus (DM) is known to cause metabolic disturbances within the extracellular matrix in multiple tissues. These alterations may play a major role in the severity of clinical symptoms of LSCS affecting diabetic patients. We aimed to examine the hypothesis that DM may contribute to the LF changes seen in patients with LSCS.

METHODS

The study cohort included 29 patients: 23 with LSCS (10 with DM vs. 13 without DM) as well as six patients with lumbar disc herniation (LDH). Surgical LF specimens were retrieved for histological assessment. Morphologic quantification of confocal microscopy images using fast Fourier transform analysis allowed us to compare anisotropy and elastin fiber orientation between groups.

RESULTS

There was a significant positive correlation between fasting plasma glucose values and degree of elastin degradation (r = 0.36, p = 0.043). The diabetic patients with LSCS showed a significantly greater loss of elastic fibers (2.3 ± 0.9 vs. 1.5 ± 0.55, p = 0.009), although fibrosis was shown to be similar (1.44 ± 0.7 vs. 1.43 ± 0.88, p = 0.98). There was no significant difference in the degree of calcification in the LSCS group between patients with and without diabetes (1.71 vs. 2.05%, p = 0.653). Fiber orientation was found to be less homogenous in the LSCS compared with the LDH group, although not significantly affected by DM.

CONCLUSIONS

The present study points to a significant contribution of DM to the loss of elastin fibers that occurs in the LF of patients with LSCS.

Comparison of postoperative clinical outcome after repairing surgery for lumbar spinal stenosis between diabetic and nondiabetic patients

Background:

Poorer postoperative outcome is suggested after repairing surgery in diabetic patients with lumbar spinal stenosis in comparison with nondiabetic patients. The present study aimed to compare the clinical outcome of surgery for lumbar spinal stenosis and diabetic and nondiabetic patients to highlight the effect of diabetes on prognosis of this surgical procedure.

Methods:

This prospective cohort study is conducted on 25 diabetic patients with lumbar spinal stenosis who were candidate for surgical treatment. A gender, age, and body mass index-matched group including 30 nondiabetic patients with lumbar spinal stenosis was considered as the control. The clinical condition of the patients was assessed based on oswestry disability index (ODI) before and immediately after surgery.

Results:

There was no difference in baseline ODI index between diabetes and diabetes group (73.68 ± 18.89 vs. 71.20 ± 18.27, P = 0.625), whereas postprocedure ODI was significantly higher in diabetic patients than in nondiabetic group (54.32 ± 19.03 vs. 29.47 ± 18.75, P < 0.001). The multivariable logistic regression analysis could show a difference in postoperative ODI between diabetic and nondiabetic patients with the presence of baseline variables as the confounders (beta = −24.509, P < 0.001).

Conclusion:

Lower improvement in physical ability is expected in diabetic patients after surgery for lumbar spinal stenosis when compared to nondiabetes patients.

The prevalence and impact of sarcopenia on degenerative lumbar spinal stenosis

AIMS

The purpose of this study was to investigate the prevalence of sarcopenia and to examine its impact on patients with degenerative lumbar spinal stenosis (DLSS).

PATIENTS AND METHODS

This case-control study included two groups: one group consisting of patients with DLSS and a second group of control subjects without low back or neck pain and related leg pain. Five control cases were randomly selected and matched by age and gender (n = 77 cases and n = 385 controls) for each DLSS case. Appendicular muscle mass, hand-grip strength, sit-to-stand test, timed up and go (TUG) test, and clinical outcomes, including the Oswestry Disability Index (ODI) scores and the EuroQol EQ-5D were compared between the two groups.

RESULTS

The prevalence of sarcopenia, as defined by hand-grip strength, was significantly higher in the DLSS group (24%) when compared with the age- and gender-matched control group (12%) (p = 0.004). In the DLSS group, the sarcopenia subgroup demonstrated inferior results for the TUG test and ODI scores when compared with the non-sarcopenia subgroup (p = 0.006 and p = 0.039, respectively) after adjusting for age and gender.

CONCLUSION

This study demonstrated a higher prevalence of sarcopenia in patients with DLSS and highlighted its negative effect on clinical outcomes. Cite this article: Bone Joint J 2016;98-B:1093-8.

Changes in HbA1c levels and body mass index after successful decompression surgery in patients with type 2 diabetes mellitus and lumbar spinal stenosis: results of a 2-year follow-up study

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) can hinder a patient's physical activity, which in turn can impair glucose tolerance and body weight regulation in patients with type 2 diabetes mellitus (DM-2). Therefore, successful lumbar surgery could facilitate glycemic control and body weight regulation.

PURPOSE

This study aimed to evaluate the effects of postoperative improvement in physical activity on body mass index (BMI) and hemoglobin A_1c (HbA_1c) level in patients with LSS and DM-2 over a 2-year follow-up period.

STUDY DESIGN

Prospective longitudinal observational study.

PATIENT SAMPLE

Patients with LSS and DM-2.

OUTCOME MEASURES

Visual analogue scale (VAS) scores for back pain and leg pain, Oswestry Disability Index (ODI) scores, Japanese Orthopaedic Association (JOA) scores, JOA Back Pain Evaluation Questionnaire (JOABPEQ) sections, BMI, and blood analysis for HbA_1c were carried out.

METHODS

A total of 119 patients were enrolled for analysis of the effect of successful decompression surgery on changes in HbA_1c levels and BMI. The VAS score, ODI score, JOA score, JOABPEQ, BMI, HbA_1c were reassessed at 6 months, 1 year, and 2 years after surgery. Additionally, correlations between changes in HbA_1c and changes in the ODI, JOA, JOABPEQs, and BMI were analyzed.

RESULTS

The overall values of HbA1c before and at 6 months, 1 year, and 2 years after the surgery were 7.08±0.94%, 6.58±0.87%, 6.59±0.79%, and 6.59±0.79%, respectively (p-values; 6 months: .024; 1 year: .021; 2 years: .038). In the not well-controlled sugar (non-WCS) group (preoperative HbA_1c>6.5%), the difference between pre- and postoperative HbA_1c was highly statistically significant (p<.01). The overweight group (preoperative BMI≥25) showed statistically significant BMI reduction in the second year after surgery (p=.034). The postoperative HbA_1c changes are strongly correlated with the improvements of ODI, JOA, and JOABPEQ after surgery.

CONCLUSIONS

The present study demonstrates that in patients with DM-2 and LSS, successful lumbar surgery may facilitate glycemic control by enabling an increase in the patient's level of physical activity. Additionally, it could help reduce body weight in overweight (BMI>25) patients with DM-2 and LSS.