Patients with predominantly back pain at the time of lumbar fusion for low-grade spondylolisthesis experience similar clinical improvement to patients with predominantly leg pain: mid-term results

Does Preoperative Back Pain Impact Patient-reported Outcomes in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Isthmic Spondylolisthesis?

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine postoperative clinical outcomes in patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for isthmic spondylolisthesis (IS).

BACKGROUND

Few studies have examined the postoperative clinical trajectory in patients undergoing MIS-TLIF specifically for IS.

METHODS

Patients were separated into two cohorts based on the previously defined Visual Analog Scale (VAS) back pain (BP) for severe pain: VAS-BP <7 and VAS-BP ≥7. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-physical function (PF), 12-item Short Form (SF-12) Physical/Mental Component Score, Patient Health Questionnaire-9, VAS-BP, VAS leg pain, and Oswestry Disability Index were collected preoperatively and up to 2-year postoperatively. Minimum clinically important difference (MCID) was calculated through previously defined thresholds.

RESULTS

A total of 160 patients were recorded, with 58 patients in the VAS-BP <7 cohort. The VAS-BP <7 cohort demonstrated significant improvement in all PROMs at one or more postoperative time points. The VAS-BP ≥7 demonstrated significant improvement at 3 or more postoperative time points in all PROMs except for SF-12 Mental Component Score. The VAS-BP <7 cohort reported significantly superior preoperative and postoperative PROMs in all domains, except for SF-12 Physical Component Score. The VAS-BP ≥7 cohort had higher MCID achievement rates at one or more time points in multiple PROMs.

CONCLUSION

Patients undergoing MIS-TLIF for IS demonstrated significant postoperative improvement in PF, mental function, pain, and disability outcomes independent of preoperative severity of BP. Patients with lower preoperative BP demonstrated superior outcomes in PF, mental function, pain, and disability. However, patients with greater preoperative BP achieved higher rates of MCID in mental function, BP, and disability outcomes. Patients with greater severity of preoperative BP undergoing MIS-TLIF for IS may experience greater rates of clinically relevant improvement in mental function, BP, and disability outcomes.

A systematic review and meta-analysis of risk factors for reoperation after degenerative lumbar spondylolisthesis surgery

BACKGROUND

Considering the high reoperation rate in degenerative lumbar spondylolisthesis (DLS) patients undergoing lumbar surgeries and controversial results on the risk factors for the reoperation, we performed a systematic review and meta-analysis to explore the reoperation rate and risk factors for the reoperation in DLS patients undergoing lumbar surgeries.

METHODS

Literature search was conducted from inception to October 28, 2022 in Pubmed, Embase, Cochrane Library, and Web of Science. Odds ratio (OR) was used as the effect index for the categorical data, and effect size was expressed as 95% confidence interval (CI). Heterogeneity test was performed for each outcome effect size, and subgroup analysis was performed based on study design, patients, surgery types, follow-up time, and quality of studies to explore the source of heterogeneity. Results of all outcomes were examined by sensitivity analysis. Publication bias was assessed using Begg test, and adjusted using trim-and-fill analysis.

RESULTS

A total of 39 cohort studies (27 retrospective cohort studies and 12 prospective cohort studies) were finally included in this systematic review and meta-analysis. The overall results showed a 10% (95%CI: 8%-12%) of reoperation rate in DLS patients undergoing lumbar surgeries. In surgery types subgroup, the reoperation rate was 11% (95%CI: 9%-13%) for decompression, 10% (95%CI: 7%-12%) for fusion, and 9% (95%CI: 5%-13%) for decompression and fusion. An increased risk of reoperation was found in patients with obesity (OR = 1.91, 95%CI: 1.04-3.51), diabetes (OR = 2.01, 95%CI: 1.43-2.82), and smoking (OR = 1.51, 95%CI: 1.23-1.84).

CONCLUSIONS

We found a 10% of reoperation rate in DLS patients after lumbar surgeries. Obesity, diabetes, and smoking were risk factors for the reoperation.

Do preoperative clinical and radiographic characteristics impact patient outcomes following one-level minimally invasive transforaminal lumbar interbody fusion based upon presenting symptoms?

BACKGROUND CONTEXT

Patients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) frequently present with lower extremity neurologic symptoms with or without associated lower back pain. While symptomatic improvement of leg and back pain has been reported, the resolution of back pain when it is a predominant presenting symptom remains underreported following MI-TLIF.

PURPOSE

The purpose of this study was to compare clinical outcomes at 1 year of patients undergoing MI-TLIF with lower extremity neurologic symptoms with and without a significant component of back pain.

STUDY DESIGN

A retrospective review of prospectively collected data from a single surgeon surgical database from 2017 to 2019 was performed.

PATIENT SAMPLE

Fifty one patients undergoing MI-TLIF.

OUTCOME MEASURES

Self-reported measures included the Oswestry Disability Index (ODI), Visual analog scale back pain (VAS-back), and VAS leg pain (VAS-leg).

METHODS

Patients were divided into two groups: Leg Pain Predominant (patients reported greater than 50% leg pain upon presentation) and Back Pain Predominant (patients reported 50% or greater back pain). Multivariate analysis was performed to determine differences between groups based upon any significantly baseline characteristics.

RESULTS

Preoperative demographic and radiographic outcomes were similar between the two groups. Both groups demonstrated significant improvement in ODI, VAS-Back and VAS-leg at 1-year postoperatively. On multivariate analysis, there were differences in ODI at 1-year, 1-year back pain, and 1-year leg pain between groups with those who initially presented with leg pain having a lower ODI, VAS Back, and VAS leg. Patients who presented with predominantly leg pain were more likely to meet minimal clinically important difference (MCID) criteria for ODI and VAS-back compared to those with predominantly back pain.

CONCLUSION

Following MI-TLIF, patients with lower extremity neurologic symptoms with and without a significant component of back pain have improvements in back pain, leg pain, and ODI regardless of their primary presenting pain complaint; however, patients who presented with predominantly leg pain were more likely to meet MCID criteria for improvement in their back pain and ODI score.

Oblique Lumbar Interbody Fusion Using a Stand-Alone Construct for the Treatment of Adjacent-Segment Lumbar Degenerative Disease

Objective

Adjacent-segment disease (ASD) is common in patients undergone previous lumbar fusion. A typical revision treatment from posterior approach requires management of postoperative scar tissue and previously implanted instrumentation. An oblique lumbar interbody fusion (OLIF) approach allows surgeon to reduce the potential risk of posterior approach. This study aimed to analyze the clinical and radiographic efficacy of stand-alone OLIF for the treatment of lumbar adjacent-segment disease.

Methods

A total of 13 consecutive patients who underwent stand-alone OLIF for the treatment of adjacent-segment disease from December 2016 to January 2019 were reviewed. Visual analog scale (VAS) of back pain and leg pain and the Oswestry Disability Index (ODI) before surgery and at last postoperative clinic visits were obtained. Radiography, CT and MRI before and at last follow-up after surgery was evaluated in all patients.

Results

During the study period, 13 cases were successfully treated with stand-alone OLIF. The mean follow-up was 17.7 ± 8.3 months. The back pain VAS improved from 6.2 ± 1.0 to 2.0 ± 1.1 (P < 0.01), and the leg pain VAS improved from 7.0 ± 1.9 to 1.0 ± 0.9 (P < 0.01). ODI improved from 28.0 ± 7.5 to 10.8 ± 4.0 (P < 0.01). The disc height (DH) increased from 9 ± 2 to 12 ± 2 mm (P < 0.01), the cross-sectional area (CSA) of spinal canal increased from 85 ± 26 to 132 ± 24 mm² (P < 0.01), the foraminal height increased from 17 ± 2 to 21 ± 3 mm (P < 0.01) and the CSA of foramen increased from 95 ± 25 to 155 ± 36 mm² (P < 0.01). Cage subsidence was observed in 2 cases.

Conclusions

Stand-alone OLIF provides a safe and effective alternative way to treat ASD.

Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction, and Return to Work After Minimally Invasive Transforaminal Lumbar Interbody Fusion For Degenerative Spondylolisthesis?

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

The objective of this study was to determine how different combinations of preoperative back pain (BP) and leg pain (LP) may influence functional outcomes, patient satisfaction and return to work (RTW) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Surgical decision-making is often based on the traditional assumption that the predominance of lower extremity symptoms is a stronger indication for lumbar spine surgery. Surprisingly, there is a paucity of literature supporting this notion and the isolated impact of the preoperative pattern of pain on outcome remains unclear.

METHODS

Prospectively collected data for patients who underwent primary MIS-TLIF for degenerative spondylolisthesis were reviewed. Patients were categorized into 3 groups depending on predominant pain location: LP predominant (LP>BP), back pain predominant [(BPP); BP>LP] and equal pain predominance (BP=LP). Patients were prospectively followed for at least 2 years.

RESULTS

In total, 781 patients were included: 33.4% LP predominant, 28.7% BPP and 37.9% equal pain predominance cases. The BPP group was significantly younger (P=0.005) and showed a trend towards poorer baseline Short-Form-36 Mental Component Summary (P=0.069). After adjusting for baseline differences, there was no significant difference in BP, LP, Oswestry Disability Index (ODI), SF-36 Physical Component Summary, and SF-36 Mental Component Summary between the 3 groups at all time points (P>0.05) except for poorer 1-month ODI in the BPP group (P=0.010). The rate of minimal clinically important difference attainment for ODI and SF-36 Physical Component Summary, satisfaction, expectation fulfilment and RTW were also similar (P>0.05).

CONCLUSIONS

The functional outcomes, quality of life and satisfaction after MIS-TLIF were similar, regardless of the predominant pain location. Equal proportions of patients achieved the minimal clinically important difference and RTW. In the context of proper indications, these results suggest that MIS-TLIF can be equally effective for patients with varying combinations of BP or LP.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

Surgery for Lumbar Spinal Stenosis in Patients With Mild Leg Pain Levels Is Associated With Unsatisfactory Outcome

STUDY DESIGN

Prospective register cohort study.

OBJECTIVES

The indication for surgery in patients with lumbar spinal stenosis (LSS) is considered to be leg pain and neurogenic claudication (NC). Nevertheless, a significant part of patients operated for LSS have mild leg pain levels defined as leg pain ≤minimally important clinical difference (MICD). Information is lacking on how to inform these patients about the probable outcome of surgery. The objective was to report the outcome of surgery for LSS in patients with a mild preoperative level of leg pain.

METHODS

A total of 2559 patients operated upon for LSS with preoperative leg pain ≤3 NRS (Numerical Rating Scale) were evaluated for outcome at the 1-year follow-up. NRS for back pain, the Oswestry Disability Index (ODI), and the EuroQol (EQ-5D) were used.

RESULTS

In the period 2007 to 2017, we identified 3239 patients (14%) who had mild leg pain (≤3 on the NRS). In this cohort, leg pain increased 0.40 (0.56-0.37) and back pain decreased 1.0 (0.95-1.2) at the 1-year follow up. ODI decreased 11.1 (10.2-11.4) and the EQ-5D increased 0.15 (0.17-0.14). A total of 31% reached successful outcome in terms of back pain, 43% in terms of ODI and 48% in terms of EQ-5D. 63% of the patients were satisfied with the outcome.

CONCLUSION

A minority of patients with mild leg pain levels operated upon for LSS attain MICD for back pain, ODI, and EQ-5D. The results from this study can aid the surgeon in the shared decision-making process before surgery.