Indications, techniques, and outcomes of posterior surgery for chronic low back pain

Short-Term Health Care Costs of High-Frequency Spinal Cord Stimulation for the Treatment of Postsurgical Persistent Spinal Pain Syndrome

OBJECTIVE

High-frequency spinal cord stimulation (HF-SCS) is a treatment option for postsurgical persistent spinal pain syndrome (type 2 PSPS). We aimed to determine the health care costs associated with this therapy in a nationwide cohort.

MATERIALS AND METHODS

IBM Marketscan® Research Databases were used to identify patients who underwent HF-SCS implantation from 2016 to 2019. Inclusion criteria included prior spine surgery or diagnoses of PSPS or postlaminectomy pain syndrome any time within the two years before implantation. Inpatient and outpatient service costs, medication costs, and out-of-pocket costs were collected six months before implantation (baseline) and one, three, and six months after implantation. The six-month explant rate was calculated. Costs were compared between baseline and six months after implant via Wilcoxon sign rank test.

RESULTS

In total, 332 patients were included. At baseline, patients incurred median total costs of $15,393 (Q1: $9,266, Q3: $26,216), whereas the postimplant median total costs excluding device acquisition were $727 (Q1: $309, Q3: $1,765) at one month, $2,840 (Q1: $1,170, Q3: $6,026) at three months, and $6,380 (Q1: $2,805, Q3: $12,637) at six months. The average total cost was reduced from $21,410 (SD $21,230) from baseline to $14,312 (SD $25,687) at six months after implant for an average reduction of $7,237 (95% CI = $3212-$10,777, p < 0.001). The median device acquisition costs were $42,937 (Q1: $30,102, Q3: $65,880). The explant rate within six months was 3.4% (8/234).

CONCLUSIONS

HF-SCS for PSPS was associated with significant decreases in total health care costs and offsets acquisition costs within 2.4 years. With the rising incidence of PSPS, it will be critical to use clinically effective and cost-efficient therapies for treatment.

Predictors of Recovery Following Lumbar Microdiscectomy for Sciatica: A Systematic Review and Meta-Analysis of Observational Studies

Chronic post-surgical pain is reported by up to 40% of patients after lumbar microdiscectomy for sciatica, a complaint associated with disability and loss of productivity. We conducted a systematic review of observational studies to explore factors associated with persistent leg pain and impairments after microdiscectomy for sciatica. We searched eligible studies in MEDLINE, Embase, and CINAHL that explored, in an adjusted model, predictors of persistent leg pain, physical impairment, or failure to return to work after microdiscectomy for sciatica. When possible, we pooled estimates of association using random-effects models using the Grading of Recommendations Assessment, Development, and Evaluation approach. Moderate-certainty evidence showed that the female sex probably has a small association with persistent post-surgical leg pain (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 0.63 to 2.08; absolute risk increase (ARI) = 1.8%, 95% CI = -4.7% to 11.3%), large association with failure to return to work (OR = 2.79, 95% CI = 1.27 to 6.17; ARI = 10.6%, 95% CI = 1.8% to 25.2%), and older age is probably associated with greater postoperative disability (β = 1.47 points on the 100-point Oswestry Disability Index for every 10-year increase from age (>/=18 years), 95% CI = -4.14 to 7.28). Among factors that were not possible to pool, two factors showed promise for future study, namely, legal representation and preoperative opioid use, which showed large associations with worse outcomes after surgery. The moderate-certainty evidence showed female sex is probably associated with persistent leg pain and failure to return to work and that older age is probably associated with greater post-surgical impairment after a microdiscectomy. Future research should explore the association between legal representation and preoperative opioid use with persistent pain and impairment after microdiscectomy for sciatica.

Does Workers' Compensation Status Affect Outcomes after Lumbar Spine Surgery? A Systematic Review and Meta-Analysis

Low back pain (LBP) is currently the leading cause of disability worldwide and the most common reason for workers’ compensation (WC) claims. Studies have demonstrated that receiving WC is associated with a negative prognosis following treatment for a vast range of health conditions. However, the impact of WC on outcomes after spine surgery is still controversial. The aim of this meta-analysis was to systematically review the literature and analyze the impact of compensation status on outcomes after lumbar spine surgery. A systematic search was performed on Medline, Scopus, CINAHL, EMBASE and CENTRAL databases. The review included studies of patients undergoing lumbar spine surgery in which compensation status was reported. Methodological quality was assessed through ROBINS-I and quality of evidence was estimated using the GRADE rating. A total of 26 studies with a total of 2668 patients were included in the analysis. WC patients had higher post-operative pain and disability, as well as lower satisfaction after surgery when compared to those without WC. Furthermore, WC patients demonstrated to have a delayed return to work. According to our results, compensation status is associated with poor outcomes after lumbar spine surgery. Contextualizing post-operative outcomes in clinical and work-related domains helps understand the multifactorial nature of the phenomenon.

CORRELATION BETWEEN QUALITY OF LIFE AND OSTEOLYSIS AROUND LUMBAR PEDICLE SCREWS

ABSTRACT Objective: To evaluate whether the presence of osteolysis around the pedicle screws affects the quality of life of patients who underwent posterolateral arthrodesis of the lumbosacral spine. Methods: A retrospective study of patients undergoing lumbar posterolateral or lumbosacral arthrodesis due to spinal degenerative disease. CT scans of the operated segments were performed at intervals of 45, 90, 180, and 360 postoperatively. In these tests, the presence of a peri-implant radiolucent halo was investigated, which was considered present when greater than 1mm in the coronal section. Concurrently with the completion of CT scans, the participants completed the questionnaire Oswestry Disability Index (ODI) to assess the degree of disability of the patients. Results: A total of 38 patients were evaluated, and 14 (36.84%) of them showed some degree of osteolysis around at least one pedicle screw at the end of follow-up. Of the 242 analyzed screws, 27 (11.15%) had osteolysis in the CT coronal section, with the majority of these occurrences located at the most distal level segment of the arthrodesis. There was no correlation between the presence of the osteolysis to the quality of life of patients. The quality of life has significantly improved when comparing the preoperative results with the postoperative results at different times of application of ODI. This improvement in ODI maintains linearity over time. Conclusion: There is no correlation between the presence of peri-implant osteolysis to the quality of life of patients undergoing lumbar or posterolateral lumbosacral arthrodesis in the follow-up period up to 360 days. The quality of life in postoperative has significantly improvement when compared to the preoperative period.

Reproducibility of tomographic evaluation of posterolateral lumbar arthrodesis consolidation

<sec><title>OBJECTIVE:</title><p> To evaluate interobserver agreement of Glassman classification for posterolateral lumbar spine arthrodesis.</p></sec><sec><title>METHODS:</title><p> One hundred and thirty-four CT scans from patients who underwent posterolateral arthrodesis of the lumbar and lumbosacral spine were evaluated by four observers, namely two orthopedic surgeons experienced in spine surgery and two in training in this area. Using the reconstructed tomographic images at oblique coronal plane, 299 operated levels were systematically analyzed looking for arthrodesis signals. The appearance of bone healing in each operated level was classified in five categories as proposed by Glassman to the posterolateral arthrodesis: 1) bilateral solid arthrodesis; 2) unilateral solid arthrodesis; 3) bilateral partial arthrodesis; 4) unilateral partial arthrodesis; 5) absence of arthrodesis. In a second step, the evaluation of each operated level was divided into two categories: fusion (including type 1, 2, 3, and 4) and non fusion (type 5). Statistical analysis was performed by calculating the Kappa coefficient considering the paired analysis between the two experienced observers and between the two observers in training.</p></sec><sec><title>RESULTS:</title><p> The interobserver reproducibility by the kappa coefficient for arthrodesis consolidation analysis for the classification proposed, divided into 5 types, was 0.729 for both experienced surgeons and training surgeons. Considering only two categories kappa coefficient was 0.745 between experienced surgeons and 0.795 between training surgeons. In all analyzes, we obtained high concordance power.</p></sec><sec><title>CONCLUSION:</title><p> Interobserver reproducibility was observed with high concordance in the classification proposed by Glassman for posterolateral arthrodesis of the lumbar and lumbosacral spine.</p></sec>

Estabilizações lombares dinâmicas

O funcionamento fisiológico normal da coluna depende da movimentação normal de cada unidade motora, que consiste em duas vértebras e o disco intervertebral interposto entre elas. Embora a artrodese da coluna vertebral venha sendo utilizada para o tratamento de diversas doenças da coluna, essa modalidade de tratamento acarreta a perda de movimentação dos níveis em que houve a fusão e como consequência pode sobrecarregar os níveis adjacentes podendo provocar a sua degeneração precoce. Proponentes das técnicas de estabilização dinâmicas acreditam que estas podem levar a correção dos problemas minimizando o risco de degeneração dos níveis adjacentes. Atualmente existem no mercado diversos métodos de estabilização dinâmica anteriores e posteriores. Já existem trabalhos biomecânicos que comprovam o benefício teórico de quase todos eles, porém ainda hoje, faltam ensaios clínicos que comprovem a sua utilidade e segurança por longos períodos de seguimento para o paciente. Portanto é fundamental que estes materiais sejam analisados de maneira acadêmica para que no futuro próximo possam ser utilizados em situações precisas e com segurança para os pacientes.

Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes

BACKGROUND CONTEXT

Although numerous studies have been published, controversy still exists regarding fusion and nonsurgical treatment for symptomatic degenerative lumbar spine conditions. Definite conclusions are difficult to draw because of differences in patient inclusion criteria, fusion technique, nonoperative treatment regimen, and clinical outcome measures used to determine success.

PURPOSE

The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various degenerative spine disorders using the Oswestry Disability Index (ODI) as a primary outcome measure in a systematic review. A secondary objective was to determine whether there is a difference in clinical outcomes based on the specific diagnosis.

STUDY DESIGN/SETTING

Systematic review.

PATIENT SAMPLE

Patients with low back pain of at least 12 weeks duration and older than 18 years, with prospectively collected ODI scores and at least a 12-month follow-up.

OUTCOME MEASURES

ODI and Short Form-36 (SF-36).

METHODS

A MEDLINE, HealthSTAR, CINAHL, and Cochrane database search was done using the search strategy recommended by the Cochrane Back Review Group. Proceedings from annual meetings of various spine societies and reference lists from review articles and retrieved articles were evaluated for possible inclusion. Criteria for inclusion were prospective randomized clinical trials in patients with low back pain of at least 12 weeks duration and older than 18 years; with prospectively collected ODI scores and at least a 12-month follow-up. The methodological quality of the studies was assessed using the van Tulder criteria. Data extracted from each study included demographics, study design, diagnosis, baseline and change in ODI, and baseline and change in SF-36 Physical Composite Score (PCS). The data were pooled and analyzed based on the primary reported inclusion diagnosis: degenerative disc disease (DDD), chronic low back pain (CLBP), and spondylolisthesis; and treatment: fusion (unspecified, posterior, anterior, combined) and nonsurgical.

RESULTS

Twenty-five studies met the inclusion criteria. The distribution of sex and smokers was similar across diagnoses and treatments. Patients with spondylolisthesis were older than patients with DDD and CLBP. Patients with spondylolisthesis had the greatest ODI improvement followed by patients with DDD and CLBP. The three fusion types produced similar amounts of improvement in ODI. Nonsurgical patients did not improve as much but had a lower baseline ODI. Improvements in the SF-36 PCS were fairly consistent across diagnostic groups and treatment types.

CONCLUSIONS

Substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or DDD exists. CLBP patients are less disabled and experience less improvement.

Tissue-engineering approach to regenerating the intervertebral disc

In today's world there is an ever increasing incidence of low back pain, which is generally attributed to degeneration of the intervertebral disc (IVD) in those in their second or third decade of life. The most prevalent treatment modalities involve conservative methods (physical therapy and medications) or surgical fusion of the upper and lower vertebral bodies. In the last 10 years, there has been a surge of interest in applying tissue-engineering principles to treat spinal problems associated with the IVD. Tissue engineering provides many promising advantages to treating disc degeneration; it adopts a more biological and reparative approach, whereby the main goal is to restore the properties of the disc to its pre-degenerative state. This review outlines the physiology of the IVD and the etiology of disc degeneration. Much of the research carried out in the field of tissue engineering is based on three predominant constituents: cells, scaffolds, and signals. Thus, specific attention is given to these constituents and their potential use in repairing the IVD. Some of the significant challenges involved in IVD tissue engineering are also identified, and a brief discussion regarding possible future areas of research follows.

Surgical treatment for the painful motion segment: matching technology with the indications: posterior lumbar fusion

STUDY DESIGN

A convenience literature-based review of the different techniques of posterior lumbar fusion.

OBJECTIVE

To describe the history, specific techniques, and outcomes of different methods of posterior lumbar fusion. The specific methods that were described include 1) uninstrumented posterior, posterolateral, and facet fusion, and 2) instrumented fusion using pedicle screws or facet screws.

SUMMARY OF BACKGROUND DATA

There are various posterior fusion techniques available for the treatment of degenerative lumbar spine conditions. Each individual technique has specific technical demands, indications, advantages, and disadvantages which should be taken into consideration when performing these procedures.

METHODS

The published scientific literature on the different methods of posterior lumbar fusion was reviewed. The history, indications, advantages, disadvantages, and clinical and radiographic outcomes were described based on the literature search.

RESULTS/CONCLUSIONS

Posterior fusion techniques have been and will continue to be among the most commonly performed procedures in lumbar spine surgery. The different methods of fusion are well defined, as are the possible complications and outcomes. They are effective techniques when performed on appropriately selected patients by a surgeon knowledgeable in the techniques and indications. Further studies are needed regarding promising but relatively unproven developments such as minimally invasive surgery and the use of osteoinductive agents.

Dynamic stabilization in the surgical management of painful lumbar spinal disorders

STUDY DESIGN

A literature review.

OBJECTIVE

To evaluate the mechanisms of action and effectiveness of posterior dynamic stabilization devices in the management of painful spinal disorders.

SUMMARY OF BACKGROUND DATA

Dynamic stabilization may provide pain relief by altering the transmission of abnormal loads across the degenerated disc space.

METHODS

A Medline search was conducted.

RESULTS

Articles supporting abnormal load transmission across the disc space and clinical reviews of currently available posterior dynamic systems were included.

CONCLUSIONS

Posterior dynamic stabilization systems may provide benefit comparable to fusion techniques, but without the elimination of movement. Further study is required to determine optimal design and clinical indications.