Risk factors for reoperation after lumbar spine surgery in a 10-year Korean national health insurance service health examinee cohort

Impact of surgical risk factors for non-union on lumbar spinal fusion outcomes using cellular bone allograft at 24-months follow-up

BACKGROUND

The current report investigates fusion rates and patient-reported outcomes following lumbar spinal surgery using cellular bone allograft (CBA) in patients with risk factors for non-union.

METHODS

A prospective, open label study was conducted in subjects undergoing lumbar spinal fusion with CBA (NCT02969616) to assess fusion success rates and patient-reported outcomes in subjects with risk factors for non-union. Subjects were categorized into low-risk (≤ 1 risk factors) and high-risk (> 1 risk factors) groups. Radiographic fusion status was evaluated by an independent review of dynamic radiographs and CT scans. Patient-reported outcome measures included quality of life (EQ-5D), Oswestry Disability Index (ODI) and Visual Analog Scales (VAS) for back and leg pain. Adverse event reporting was conducted throughout 24-months of follow-up.

RESULTS

A total of 274 subjects were enrolled: 140 subjects (51.1%) were categorized into the high-risk group (> 1 risk factor) and 134 subjects (48.9%) into the low-risk group (≤ 1 risk factors). The overall mean age at screening was 58.8 years (SD 12.5) with a higher distribution of females (63.1%) than males (36.9%). No statistical difference in fusion rates were observed between the low-risk (90.0%) and high-risk (93.9%) groups (p > 0.05). A statistically significant improvement in patient-reported outcomes (EQ-5D, ODI and VAS) was observed at all time points (p < 0.05) in both low and high-risk groups. The low-risk group showed enhanced improvement at multiple timepoints in EQ-5D, ODI, VAS-Back pain and VAS-Leg pain scores compared to the high-risk group (p < 0.05). The number of AEs were similar among risk groups.

CONCLUSIONS

This study demonstrates high fusion rates following lumbar spinal surgery using CBA, regardless of associated risk factors. Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles.

TRIAL REGISTRATION

NCT02969616 (21/11/2016).

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review

BACKGROUND CONTEXT

Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression.

PURPOSE

To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years.

OUTCOME MEASURES

The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery.

METHODS

Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors.

RESULTS

A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively.

CONCLUSIONS

Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Analysis of factors associated with the use of Korean medicine after spinal surgery using a nationwide database in Korea

Many patients in Korea use Korean Medicine (KM) after spine surgery, but related research is lacking. Therefore, this retrospective cohort study aimed to analyze factors affecting the use and costs of KM using nationally representative data from the National Health Insurance Service-National Sample Cohort, South Korea. Patients who underwent spinal surgery for spinal diseases from 2011 to 2014 were followed up for 5 years, and their medical care was described. The association between patient and spinal surgery characteristics and the use of KM was analyzed. A two-part model was used to analyze factors affecting the use of KM in patients undergoing spinal surgery. Of 11,802 patients who underwent spinal surgery, 11,367 who met the inclusion criteria were included. Overall, 55.5% were female, 32.3% were aged ≥ 70 years, and 50.2% received KM treatment during the follow-up period. Open discectomy was the most common surgical procedure performed (58.6%), and 40.2% of surgeries were performed because of lumbar disc disorder. Female sex, older age, high Charlson Comorbidity Index score, and use of KM before surgery were associated with increased KM use and expenditure after surgery. In conclusion, patient characteristics, rather than surgical characteristics, appeared to be more strongly associated with the use of KM after surgery, particularly prior experience with KM use. This study is significant in that it analyzed the entire spine surgery to provide a comprehensive view of the use of KM after spine surgery and analyzed the impact of various factors related patients and surgical characteristics on KM use. The results of this study may be useful to patients with spinal diseases, clinicians, and policymakers.

Imaging evaluation of a proposed 3D generative model for MRI to CT translation in the lumbar spine

BACKGROUND CONTEXT

A computed tomography (CT) and magnetic resonance imaging (MRI) are used routinely in the radiologic evaluation and surgical planning of patients with lumbar spine pathology, with the modalities being complimentary. We have developed a deep learning algorithm which can produce 3D lumbar spine CT images from MRI data alone. This has the potential to reduce radiation to the patient as well as burden on the health care system.

PURPOSE

The purpose of this study is to evaluate the accuracy of the synthetic lumbar spine CT images produced using our deep learning model.

STUDY DESIGN

A training set of 400 unpaired CTs and 400 unpaired MRI scans of the lumbar spine was used to train a supervised 3D cycle-Gan model. Evaluators performed a set of clinically relevant measurements on 20 matched synthetic CTs and true CTs. These measurements were then compared to assess the accuracy of the synthetic CTs.

PATIENT SAMPLE

The evaluation data set consisted of 20 patients who had CT and MRI scans performed within a 30-day period of each other. All patient data was deidentified. Notable exclusions included artefact from patient motion, metallic implants or any intervention performed in the 30 day intervening period.

OUTCOME MEASURES

The outcome measured was the mean difference in measurements performed by the group of evaluators between real CT and synthetic CTs in terms of absolute and relative error.

METHODS

Data from the 20 MRI scans was supplied to our deep learning model which produced 20 "synthetic CT" scans. This formed the evaluation data set. Four clinical evaluators consisting of neurosurgeons and radiologists performed a set of 24 clinically relevant measurements on matched synthetic CT and true CTs in 20 patients. A test set of measurements were performed prior to commencing data collection to identify any significant interobserver variation in measurement technique.

RESULTS

The measurements performed in the sagittal plane were all within 10% relative error with the majority within 5% relative error. The pedicle measurements performed in the axial plane were considerably less accurate with a relative error of up to 34%.

CONCLUSIONS

The computer generated synthetic CTs demonstrated a high level of accuracy for the measurements performed in-plane to the original MRIs used for synthesis. The measurements performed on the axial reconstructed images were less accurate, attributable to the images being synthesized from nonvolumetric routine sagittal T1-weighted MRI sequences. It is hypothesized that if axial sequences or volumetric data were input into the algorithm these measurements would have improved accuracy.

How to spot the recurring lumbar disc? Risk factors for recurrent lumbar disc herniation (rLDH) in adult patients with lumbar disc prolapse: a systematic review and meta-analysis

Despite a fast-growing evidence-base examining the relationship of certain clinical and radiological factors such as smoking, BMI and herniation-type with rLDH, there remains much debate around which factors are clinically important. We conducted a systematic review and meta-analysis to identify risk factors for recurrent lumbar disc herniation (rLDH) in adults after primary discectomy. A systematic literature search was carried out using Ovid-Medline, EMBASE, Cochrane library and Web of Science databases from inception to 23rd June-2022. Observational studies of adult patients with radiologically-confirmed rLDH after ≥3 months of the initial surgery were included, and their quality assessed using the Quality-In-Prognostic-Studies (QUIPS) appraisal tool. Meta-analyses of univariate and multivariate data and a sensitivity-analysis for rLDH post-microdiscectomy were performed. Twelve studies (n=4497, mean age:47.3; 34.5% female) were included, and 11 studies (n=4235) meta-analysed. The mean follow-up was 38.4 months. Mean recurrence rate was 13.1% and mean time-to-recurrence was 24.1 months (range: 6-90 months). Clinically, older age (OR:1.04, 95%CI:1.00-1.08, n=1014), diabetes mellitus (OR:3.82, 95%CI:1.58-9.26, n=2330) and smoking (OR:1.80, 95%CI:1.03- 3.14, n=3425) increased likelihood of recurrence. Radiologically, Modic-change type-2 (OR:7.93, 95%CI:5.70-11.05, n=1706) and disc extrusion (OR:12.23, 95%CI:8.60-17.38, n=1706) increased likelihood of recurrence. The evidence did not support an association between rLDH and sex; BMI; occupational labour/driving; alcohol-consumption; Pfirmann- grade, or herniation-level. Older patients, smokers, patients with diabetes, those with type-2 Modic-changes or disc extrusion are more likely to experience rLDH. Higher quality studies with robust adjustment of confounders are required to determine the clinical bearing of all other potential risk factors for rLDH.

Adverse Surgical Outcomes Linked to Co-occurring Smoking and Risky Alcohol Use Among General Surgery Patients

OBJECTIVE

To assess associations between co-occurring preoperative smoking and risky alcohol use on the likelihood of adverse surgical outcomes.

BACKGROUND

Risky alcohol use and smoking are the known surgical risk factors with a high co-occurrence and additive adverse effects on multiple organ systems that impact surgical health, yet no research has evaluated the impact of co-occurrence on surgical outcomes.

METHODS

This investigation analyzed 200,816 patients from the Michigan Surgical Quality Collaborative database between July 1, 2012, to December 31, 2018. Patients were classified based on past year risky alcohol use (>2 drink/day) and cigarette smoking into 4 groups: (1) risky alcohol and smoking, (2) risky alcohol only, (3) smoking only, and (4) no risky alcohol/smoking. We fitted logistic regression models, applying propensity score weights incorporating demographic, clinical, and surgical factors to assess associations between alcohol and smoking and 30-day postoperative outcomes; surgical complications, readmission, reoperation, and emergency department (ED) visits.

RESULTS

Risky alcohol and smoking, risky alcohol only, and smoking only were reported by 2852 (1.4%), 2840 (1.4%), and 44,042 (22%) patients, respectively. Relative to all other groups, the alcohol and smoking group had greater odds of surgical complications, readmission, and reoperation. Relative to the no alcohol and smoking group, the alcohol only group higher odds of reoperation and smoking only group had higher odds of emergency department visits.

CONCLUSIONS

The combination of smoking and risky drinking conferred the highest likelihood of complications, readmission, and reoperation before surgery. Co-occurring alcohol and smoking at the time of surgery warrants special attention as a patient risk factor and deserves additional research.

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.

Laminectomy With Fusion is Associated With Greater Functional Improvement Compared With Laminectomy Alone for the Treatment of Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and Meta-analysis.

OBJECTIVE

To compare outcomes and complications profile of laminectomy alone versus laminectomy and fusion for the treatment of degenerative lumbar spondylolisthesis (DLS).

SUMMARY OF BACKGROUND DATA

Degenerative lumbar spondylolisthesis is a common cause of back pain and functional impairment. DLS is associated with high monetary (up to $100 billion annually in the US) and nonmonetary societal and personal costs. While nonoperative management remains the first-line treatment for DLS, decompressive laminectomy with or without fusion is indicated for the treatment-resistant disease.

METHODS

We systematically searched PubMed and EMBASE for RCTs and cohort studies from inception through April 14, 2022. Data were pooled using random-effects meta-analysis. The risk of bias was assessed using the Joanna Briggs Institute risk of bias tool. We generated odds ratio and standard mean difference estimates for select parameters.

RESULTS

A total of 23 manuscripts were included (n=90,996 patients). Complication rates were higher in patients undergoing laminectomy and fusion compared with laminectomy alone (OR: 1.55, P <0.001). Rates of reoperation were similar between both groups (OR: 0.67, P =0.10). Laminectomy with fusion was associated with a longer duration of surgery (Standard Mean Difference: 2.60, P =0.04) and a longer hospital stay (2.16, P =0.01). Compared with laminectomy alone, the extent of functional improvement in pain and disability was superior in the laminectomy and fusion cohort. Laminectomy with fusion had a greater mean change in ODI (-0.38, P <0.01) compared with laminectomy alone. Laminectomy with fusion was associated with a greater mean change in NRS leg score (-0.11, P =0.04) and NRS back score (-0.45, P <0.01).

CONCLUSION

Compared with laminectomy alone, laminectomy with fusion is associated with greater postoperative improvement in pain and disability, albeit with a longer duration of surgery and hospital stay.

Sarcopenia and Postoperative Complications, Cost of Care, and All-Cause Hospital Readmission Following Lumbar Spine Arthrodesis: A Propensity Matched Cohort Study

OBJECTIVE

Sarcopenia, characterized by decreased muscle mass and function, is projected to affect more than 200 million people worldwide by 2060. This study aimed to evaluate the rates of short-term complications following lumbar spine arthrodesis in patients with and without a recent diagnosis of sarcopenia.

METHODS

The PearlDiver database was queried to evaluate all patients who underwent index lumbar spine arthrodesis from 2012 to 2019. Multivariate logistic regression was used to compare rates of 90-day surgical and medical complications. Kaplan-Meier analysis was performed to compare cumulative rates of reoperation and all-cause hospital readmission. Two sample t testing was used to compare costs of care. Statistical significance was set at P < 0.05 a priori.

RESULTS

Of 239,953 patients undergoing lumbar spine arthrodesis, 1087 had a recent diagnosis of sarcopenia (0.45%) before surgery. Patients with sarcopenia were significantly more likely to experience a urinary tract infection (odds ratio = 1.41, P = 0.035) and undergo incision and drainage (odds ratio = 2.66, P = 0.010) within 90 days after lumbar arthrodesis. Patients with sarcopeniawere at a 24% greater risk of 1-year all-cause hospital readmission. The 90-day cost of care was significantly greater in patients with sarcopenia ($37,689.86 vs. $26,635.72; P < 0.001).

CONCLUSIONS

In patients undergoing lumbar spine arthrodesis, sarcopenia is associated with an increased risk of postoperative complications, including increased costs of care. Spine surgeons should consider screening patients for sarcopenia preoperatively and counsel them regarding their increased risk of complications. Additionally, surgeons may consider preoperative optimization, like the management of low bone density.

A 9-year retrospective cohort of patients with lumbar disc herniation: Comparison of patient characteristics and recurrence frequency by smoking status

To evaluate the association between smoking status and patient characteristics and to identify risk factors associated with recurrence in patients who underwent surgery for lumbar disc herniation (LDH). This retrospective study was carried out at Lokman Hekim University, Ankara, Turkey between January 1, 2021 and January 1, 2022. The medical data of patients who underwent microsurgical discectomy for LDH were retrospectively recorded. Patients with any reemergence of LDH within a 6-month period after surgery were defined as having recurrent LDH. A total of 1109 patients were included in the study and mean age was 50.7 ± 14.3 years. The frequency of hernia at L2-L3 and L3-L4 levels was higher in the nonsmoker group (P < .001). The frequency of cases with Pfirrmann Grade 4 degeneration was higher in the nonsmoker group than in smokers and ex-smokers (P < .001). Protrusion-type hernias were more common in nonsmokers (P = .014), whereas paracentral hernias were more common in smokers (P < .001). The overall frequency of recurrence was 20.4%, and was higher in smokers than in non-smokers and ex-smokers (P < .001). Multivariable logistic regression revealed that current smoking (OR: 2.778, 95% CI [confidence interval]: 1.939-3.980, P < .001), presence of Pfirrmann Grade 4&5 disc degeneration (OR: 4.217, 95% CI: 2.966-5.996, P < .001), and paracentral herniation (OR: 5.040, 95% CI: 2.266-11,207, P < .001) were associated with higher risk of recurrence, whereas presence of sequestrated disc was associated with lower risk of recurrence (OR: 2.262, 95% CI:0.272-0.717, P = .001). Taken together, our data show that smoking, increased degree of degeneration and paracentral hernia increase the risk of LDH recurrence, while sequestrated disc appears to decrease risk. Taking steps to combat smoking in individuals followed for LDH may reduce the risk of recurrence in LDH patients.

Early Reoperation Rates and Its Risk Factors after Instrumented Spinal Fusion Surgery for Degenerative Spinal Disease: A Nationwide Cohort Study of 65,355 Patients

Reoperation is a major concern in spinal fusion surgery for degenerative spinal disease. Earlier reported reoperation rates were confined to a specific spinal region without comprehensive analysis, and their prediction models for reoperation were not statistically validated. Our study aimed to present reasonable base rates for reoperation according to all possible risk factors and build a validated prediction model for early reoperation. In our nationwide population-based cohort study, data between 2014 and 2016 were obtained from the Korean National Health Insurance claims database. Patients older than 19 years who underwent instrumented spinal fusion surgery for degenerative spinal diseases were included. The patients were divided into cases (patients who underwent reoperation) and controls (patients who did not undergo reoperation), and risk factors for reoperation were determined by multivariable analysis. The estimates of all statistical models were internally validated using bootstrap samples, and sensitivity analyses were additionally performed to validate the estimates by comparing the two prediction models (models for 1st-year and 3rd-year reoperation). The study included 65,355 patients: 2939 (4.5%) who underwent reoperation within 3 years after the index surgery and 62,146 controls. Reoperation rates were significantly different according to the type of surgical approach and the spinal region. The third-year reoperation rates were 5.3% in the combined lumbar approach, 5.2% in the posterior lumbar approach, 5.0% in the anterior lumbar approach, 3.0% in the posterior thoracic approach, 2.8% in the posterior cervical approach, 2.6% in the anterior cervical approach, and 1.6% in the combined cervical approach. Multivariable analysis identified older age, male sex, hospital type, comorbidities, allogeneic transfusion, longer use of steroids, cages, and types of surgical approaches as risk factors for reoperation. Clinicians can conduct comprehensive risk assessment of early reoperation in patients who will undergo instrumented spinal fusion surgery for degenerative spinal disease using this model.