Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis

Impact of age on comparative outcomes of decompression alone versus fusion for L4 degenerative spondylolisthesis

PURPOSE

To compare the outcomes of decompression alone and fusion for L4-5 DLS in different age cohorts (< 70 years, ≥ 70 years).

METHODS

This retrospective cohort study included patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up. Outcome measures were: (1) patient-reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale back and leg, VAS; 12-Item Short Form Survey Physical Component Score, SF-12 PCS), (2) minimal clinically important difference (MCID), (3) patient acceptable symptom state (PASS), (4) response on the global rating change (GRC) scale, and (5) complication rates. The decompression and fusion groups were compared for outcomes separately in the < 70-year and ≥ 70-year age cohorts.

RESULTS

233 patients were included, out of which 52% were < 70 years. Patients < 70 years showed non-significant improvement in SF-12 PCS and significantly lower MCID achievement rates for VAS back after decompression compared to fusion. Analysis of the ≥ 70-year age cohort showed no significant differences between the decompression and fusion groups in the improvement in PROMs, MCID/PASS achievement rates, and responses on GRC. Patients ≥ 70 years undergoing fusion had significantly higher in-hospital complication rates. When analyzed irrespective of the surgery type, both < 70-year and ≥ 70-year age cohorts showed significant improvement in PROMs with no significant difference.

CONCLUSIONS

Patients < 70 years undergoing decompression alone did not show significant improvement in physical function and had significantly less MCID achievement rate for back pain compared to fusion. Patients ≥ 70 years showed no difference in outcomes between decompression alone and fusion.

Lumbar Facet Arthroplasty Versus Fusion for Grade-I Degenerative Spondylolisthesis with Stenosis: A Prospective Randomized Controlled Trial

BACKGROUND

The comparative effectiveness of decompression plus lumbar facet arthroplasty versus decompression plus instrumented lumbar spinal fusion in patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis is unknown.

METHODS

In this randomized, controlled, Food and Drug Administration Investigational Device Exemption trial, we assigned patients who had single-level lumbar spinal stenosis and grade-I degenerative spondylolisthesis to undergo decompression plus lumbar facet arthroplasty (arthroplasty group) or decompression plus fusion (fusion group). The primary outcome was a predetermined composite clinical success score. Secondary outcomes included the Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, Zurich Claudication Questionnaire (ZCQ), Short Form (SF)-12, radiographic parameters, surgical variables, and complications.

RESULTS

A total of 321 adult patients were randomized in a 2:1 fashion, with 219 patients assigned to undergo facet arthroplasty and 102 patients assigned to undergo fusion. Of these, 113 patients (51.6%) in the arthroplasty group and 47 (46.1%) in the fusion group who had either reached 24 months of postoperative follow-up or were deemed early clinical failures were included in the primary outcome analysis. The arthroplasty group had a higher proportion of patients who achieved composite clinical success than did the fusion group (73.5% versus 25.5%; p < 0.001), equating to a between-group difference of 47.9% (95% confidence interval, 33.0% to 62.8%). The arthroplasty group outperformed the fusion group in most patient-reported outcome measures (including the ODI, VAS back pain, and all ZCQ component scores) at 24 months postoperatively. There were no significant differences between groups in surgical variables or complications, except that the fusion group had a higher rate of developing symptomatic adjacent segment degeneration.

CONCLUSIONS

Among patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis, lumbar facet arthroplasty was associated with a higher rate of composite clinical success than fusion was at 24 months postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Lumbar Decompression With and Without Fusion for Lumbar Stenosis With Spondylolisthesis: A Cost Utility Analysis

STUDY DESIGN

Markov model.

OBJECTIVE

To compare the cost-effectiveness of lumbar decompression alone (DA) with lumbar decompression with fusion (DF) for the management of adults undergoing surgery for lumbar stenosis with associated degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Rates of lumbar fusion have increased for all indications in the United States over the last 20 years. Recent randomized controlled trial data, however, have suggested comparable functional outcomes and lower reoperation rates for lumbar decompression and fusion as compared with DA in the treatment of lumbar stenosis with degenerative spondylolisthesis.

MATERIALS AND METHODS

A multistate Markov model was constructed from the US payer perspective of a hypothetical cohort of patients with lumbar stenosis with associated spondylolisthesis requiring surgery. Data regarding clinical improvement, costs, and reoperation were generated from contemporary randomized trial evidence, meta-analyses of recent prospective studies, and large retrospective cohorts. Base case, one-way sensitivity analysis, and probabilistic sensitivity analyses were conducted, and the results were compared with a WTP threshold of $100,000 (in 2022 USD) over a two-year time horizon. A discount rate of 3% was utilized.

RESULTS

The incremental cost and utility of DF relative to DA were $12,778 and 0.00529 aggregated quality adjusted life years. The corresponding incremental cost-effectiveness ratio of $2,416,281 far exceeded the willingness to pay threshold of $100,000. In sensitivity analysis, the results varied the most with respect to rate of improvement after DA, rate of improvement after lumbar decompression and fusion, and odds ratio of reoperation between the two groups. Zero percent of one-way and probabilistic sensitivity analyses achieved cost-effectiveness at the willingness-to-pay threshold.

CONCLUSIONS

Within the context of contemporary surgical data, DF is not cost-effective compared with DA in the surgical management of lumbar stenosis with associated spondylolisthesis over a two-year time horizon.

Distal Lumbar Lordosis is Associated With Reoperation for Adjacent Segment Disease After Lumbar Fusion for Degenerative Conditions

STUDY DESIGN

A single centre retrospective review.

OBJECTIVE

Recent studies have suggested that distal lordosis (L4-S1, DL) remains constant across all pelvic incidence (PI) subgroups, whilst proximal lordosis (L1-L4, PL) varies. We sought to investigate the impact of post-operative DL on adjacent segment disease (ASD) requiring reoperation in patients undergoing lumbar fusion for degenerative conditions.

METHODS

Patients undergoing 1-3 level lumbar fusion with the two senior authors between 2007-16 were included. Demographic and radiographic data were recorded. Univariate, multivariate binary logistic regression, and Kaplan Meier survivorship analyses were performed.

RESULTS

335 patients were included in the final analysis. Most had single (67%) or two (31%) level fusions. The mean follow-up was 64-month. Fifty-seven patients (17%) underwent reoperation for ASD at an average of 78-month post-operatively (R group). The R group had a significantly lower mean post-operative DL (27.3 vs 31.1 deg, P < .001) and mean PI (55.5 vs 59.2 deg, P < .05). On univariate analysis, patients with a post-operative DL of <35 deg had higher odds of reoperation for ASD than those with a post-operative DL of ≥35 deg (OR 2.7, P = .016). In the multivariate model, post-operative DL, low/average PI, and spondylolisthesis were all significantly associated with reoperation for ASD.

CONCLUSION

This study provides preliminary support to an association between post-operative distal lumbar lordosis and risk of reoperation for ASD in patients undergoing fusions for degenerative conditions. Further multicentre prospective study is needed to independently confirm this association and identify the impact of restoration of physiological distal lumbar lordosis on long term patient outcomes.

Isolated Decompression for Degenerative Spondylolisthesis is Less Costly than Fusion Even with High Revision Rates

BACKGROUND CONTEXT

Isolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of re-operation than primary fusion.

PURPOSE

To determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis.

STUDY DESIGN/SETTING

A retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set.

PATIENT SAMPLE

Patients who underwent single-level fusion or decompression for degenerative spondylolisthesis.

OUTCOME MEASURES

Cost of surgical care.

METHODS

All inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice.

RESULTS

On univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). On multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%CI: 2,990-4,512, p<0.001). Economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients.

CONCLUSIONS

Isolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXT

Perioperative pain management affects cost and outcomes in elective spine surgery.

PURPOSE

This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization.

STUDY DESIGN

This was a retrospective comparative study.

PATIENT SAMPLE

Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores.

OUTCOME MEASURES

Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis.

METHODS

Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc.

RESULTS

In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts.

CONCLUSIONS

Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review

INTRODUCTION

Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments.

METHODS

The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria.

RESULTS

The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis.

CONCLUSIONS

There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

Development and Validation of Machine Learning-Based Predictive Model for Prolonged Hospital Stay after Decompression Surgery for Lumbar Spinal Canal Stenosis

Introduction

Precise prediction of hospital stay duration is essential for maximizing resource utilization during surgery. Existing lumbar spinal stenosis (LSS) surgery prediction models lack accuracy and generalizability. Machine learning can improve accuracy by considering preoperative factors. This study aimed to develop and validate a machine learning-based model for estimating hospital stay duration following decompression surgery for LSS.

Methods

Data from 848 patients who underwent decompression surgery for LSS at three hospitals were examined. Twelve prediction models, using 79 preoperative variables, were developed for postoperative hospital stay estimation. The top five models were chosen. Fourteen models predicted prolonged hospital stay (≥14 days), and the most accurate model was chosen. Models were validated using a randomly divided training sample (70%) and testing cohort (30%).

Results

The top five models showed moderate linear correlations (0.576-0.624) between predicted and measured values in the testing sample. The ensemble of these models had moderate prediction accuracy for final length of stay (linear correlation 0.626, absolute mean error 2.26 days, standard deviation 3.45 days). The c5.0 decision tree model was the top predictor for prolonged hospital stay, with accuracies of 89.63% (training) and 87.2% (testing). Key predictors for longer stay included JOABPEQ social life domain, facility, history of vertebral fracture, diagnosis, and Visual Analogue Scale (VAS) of low back pain.

Conclusions

A machine learning-based model was developed to predict postoperative hospital stay after LSS decompression surgery, using data from multiple hospital settings. Numerical prediction of length of stay was not very accurate, although favorable prediction of prolonged stay was accomplished using preoperative factors. The JOABPEQ social life domain score was the most important predictor.

Degenerative lumbar spondylolisthesis: review of current classifications and proposal of a novel classification system

PURPOSE

To review existing classification systems for degenerative spondylolisthesis (DS), propose a novel classification designed to better address clinically relevant radiographic and clinical features of disease, and determine the inter- and intraobserver reliability of this new system for classifying DS.

METHODS

The proposed classification system includes four components: 1) segmental dynamic instability, 2) location of spinal stenosis, 3) sagittal alignment, and 4) primary clinical presentation. To establish the reliability of this system, 12 observers graded 10 premarked test cases twice each. Kappa values were calculated to assess the inter- and intraobserver reliability for each of the four components separately.

RESULTS

Interobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation was 0.94, 0.80, 0.87, and 1.00, respectively. Intraobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation were 0.91, 0.88, 0.87, and 0.97, respectively.

CONCLUSION

The UCSF DS classification system provides a novel framework for assessing DS based on radiographic and clinical parameters with established implications for surgical treatment. The almost perfect interobserver and intraobserver reliability observed for all components of this system demonstrates that it is simple and easy to use. In clinical practice, this classification may allow subclassification of similar patients into groups that may benefit from distinct treatment strategies, leading to the development of algorithms to help guide selection of an optimal surgical approach. Future work will focus on the clinical validation of this system, with the goal of providing for more evidence-based, standardized approaches to treatment and improved outcomes for patients with DS.

A scoping review of human skeletal kinematics research using biplane radiography

Biplane radiography has emerged as the gold standard for accurately measuring in vivo skeletal kinematics during physiological loading. The purpose of this scoping review was to map the extent, range, and nature of biplane radiography research on humans from 2004 through 2022. A literature search was performed using the terms biplane radiography, dual fluoroscopy, dynamic stereo X-ray, and biplane videoradiography. All articles referenced in included publications were also assessed for inclusion. A secondary search was then performed using the names of the most frequently appearing principal investigators among included papers. A total of 379 manuscripts were identified and included. The first studies published in 2004 focused on the native knee, followed by studies of the ankle joint complex in 2006, the shoulder in 2007, and the spine in 2008. Nearly half (180, 47.5%) of all manuscripts investigated knee kinematics. The average number of publications increased from 21.6 per year from 2012 to 2017 to 34.6 per year from 2017 to 2022. The average number of participants per study was 16, with a range from 1 to 101. A total of 90.2% of studies featured cohorts of 30 or less. The most prolific research groups for each joint were: Mass General Hospital (lumbar spine and knee), Henry Ford Hospital (shoulder), the University of Utah (ankle and hip), The University of Pittsburgh (cervical spine), and Brown University (hand/wrist/elbow). Future advancements in biplane radiography research are dependent upon increased availability of these imaging systems, standardization of data collection protocols, and the development of automated approaches to expedite data processing.

Clinical effectiveness of reduction and fusion versus in situ fusion in the management of degenerative lumbar spondylolisthesis: a systematic review and meta-analysis

PURPOSE

To compare the clinical effectiveness of reduction and fusion with in situ fusion in the management of patients with degenerative lumbar spondylolisthesis (DLS).

METHODS

The systematic review was conducted following the PRISMA guidelines. Relevant studies were identified from PubMed, Embase, Scopus, Cochrane Library, ClinicalTrials.gov, and Google Scholar. The inclusion criteria were: (1) comparative studies of reduction and fusion versus in situ fusion for DLS patients, (2) outcomes reported as VAS/NRS, ODI, JOA score, operating time, blood loss, complication rate, fusion rate, or reoperation rate, (3) randomized controlled trials and observational studies published in English from the inception of the databases to January 2023. The exclusion criteria included: (1) reviews, case series, case reports, letters, and conference reports, (2) in vitro biomechanical studies and computational modeling studies, (3) no report on study outcomes. The risk of bias 2 (RoB2) tool and the Newcastle-Ottawa scale was conducted to assess the risk of bias of RCTs and observational studies, respectively.

RESULTS

Five studies with a total of 704 patients were included (375 reduction and fusion, 329 in situ fusion). Operating time was significantly longer in the reduction and fusion group compared to in situ fusion group (weighted mean difference 7.20; 95% confidence interval 0.19, 14.21; P = 0.04). No additional significant intergroup differences were noted in terms of other outcomes analyzed.

CONCLUSION

While the reduction and fusion group demonstrated a statistically longer operating time compared to the in situ fusion group, the clinical significance of this difference was minimal. The findings suggest no substantial superiority of lumbar fusion with reduction over without reduction for the management of DLS.

Radiographic predictors of reaching minimal clinically important difference following lumbar fusion surgery in patients with degenerative lumbar spondylolisthesis

PURPOSE

The present study aimed to (1) compare sagittal alignment between patients with degenerative lumbar spondylolisthesis (DLS) who reached or missed the minimal clinically important difference (MCID) for clinical outcomes following lumbar fusion surgery (LFS) and (2) identify radiographic predictors associated with MCID achievement in DLS patients.

METHODS

A total of 91 single-level DLS patients who underwent LFS and had a minimum of 1-year follow-up were enrolled in this study. The assessed radiographic parameters included thoracic kyphosis, lumbar lordosis (LL), segmental lumbar lordosis (SLL), slip percentage, sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and sagittal vertical axis. Changes in radiographic parameters were determined by subtracting the preoperative value from the final follow-up measurement. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and the visual analog scale (VAS) for both back and leg pain. MCID values were set at 10 points for ODI, 2.1 points for VAS back pain, and 2.8 points for VAS leg pain. Patients were assigned to the reached MCID (rMCID) and missed MCID (mMCID) groups based on the postoperative (post-op) recovery of clinical outcomes.

RESULTS

At the last follow-up, 68.1% (62/91), 72.5% (66/91), and 76.9% (70/91) of patients reached MCID for ODI, VAS back pain, and VAS leg pain, respectively. Concerning ODI, the rMCID group exhibited higher post-op LL (47.93° vs. 42.95°, P = 0.044), higher post-op SLL (17.08° vs. 14.41°, P = 0.032), higher post-op SS (34.46° vs. 30.63°, P = 0.027), higher ∆LL (5.90° vs. 2.44°, P = 0.017), higher ∆SLL (4.63° vs. - 1.03°, P < 0.001), higher ∆SS (4.76° vs. 1.23°, P = 0.002), lower post-op PT/PI (36.95% vs. 42.01%, P = 0.049), lower ∆PT (- 3.71° vs. 1.05°, P < 0.001), lower ∆PT/PI (- 7.45% vs. 1.97%, P < 0.001), and lower ∆PI-LL (- 5.43° vs. - 3.71°, P = 0.011) than the mMCID group. Regarding VAS back pain, the rMCID group showed higher post-op SLL (17.06° vs. 14.05°, P = 0.021), higher post-op SS (34.34° vs. 30.33°, P = 0.027), higher ∆SLL (3.93° vs. - 0.09°, P < 0.001), and lower ∆PT (- 2.91° vs. - 0.30°, P = 0.039) than the mMCID group. For VAS leg pain, higher ∆SLL (3.55° vs. 0.41°, P = 0.003) was observed in the rMCID group than in the mMCID group. Multivariate logistic regression analysis revealed that higher ∆SLL, higher ∆SS, and higher post-op SS were independent predictors for the achievement of MCID in patients with DLS.

CONCLUSION

DLS patients who reached MCID following LFS demonstrated improved post-op spinopelvic alignment. Higher ∆SLL, higher ∆SS, and higher post-op SS were the critical parameters associated with MCID achievement in patients with DLS.

Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050

BACKGROUND

Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States.

METHODS

Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index.

RESULTS

Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932).

CONCLUSIONS

The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Management for degenerative lumbar spondylolisthesis: a network meta-analysis and systematic review basing on randomized controlled trials

BACKGROUND

Consensus on the various interventions for degenerative lumbar spondylolisthesis (DLS) remains unclear.

MATERIALS AND METHODS

The authors searched PubMed, Embase, Cochrane Library, Web of Science, and major scientific websites until 01 November 2023, to screen eligible randomized controlled trials (RCTs) involving the treatment of DLS. The seven most common DLS interventions [nonsurgical (NS), decompression only (DO), decompression plus fusion without internal fixation (DF), decompression plus fusion with internal fixation (DFI), endoscopic decompression plus fusion (EDF), endoscopic decompression (ED), and circumferential fusion (360F)] were compared. The primary (pain and disability) and secondary (complications, reoperation rate, operation time, blood loss, length of hospital stay, and satisfaction) outcomes were analyzed.

RESULTS

Data involving 3273 patients in 16 RCTs comparing the efficacy of different interventions for DLS were reported. In terms of improving patient pain and dysfunction, there was a significant difference between surgical and NS. EDF showed the greatest improvement in short-term and long-term dysfunction (probability, 7.1 and 21.0%). Moreover, EDF had a higher complication rate (probability 70.8%), lower reoperation rate (probability, 20.2%), and caused greater blood loss (probability, 82.5%) than other surgical interventions. Endoscopic surgery had the shortest hospitalization time (EDF: probability, 42.6%; ED: probability, 3.9%). DF and DFI had the highest satisfaction scores.

CONCLUSIONS

Despite the high complication rate of EDF, its advantages include improvement in pain, lower reoperation rate, and shorter hospitalization duration. Therefore, EDF may be a good option for patients with DLS as a less invasive surgical approach.

Radiographic and surgery-related predictive factors for increased segmental lumbar lordosis following lumbar fusion surgery in patients with degenerative lumbar spondylolisthesis

OBJECTIVE

This study aimed to evaluate preoperative (pre-op) radiographic characteristics and specific surgical interventions in patients with degenerative lumbar spondylolisthesis (DLS) who underwent lumbar fusion surgery (LFS), with a focus on analyzing predictors of postoperative restoration of segmental lumbar lordosis (SLL).

METHODS

A retrospective review at a single center identified consecutive single-level DLS patients who underwent LFS between 2016 and 2022. Radiographic measures included disc angle (DA), SLL, lumbar lordosis (LL), anterior/posterior disc height (ADH/PDH), spondylolisthesis percentage (SP), intervertebral disc degeneration, and paraspinal muscle quality. Surgery-related measures included cage position, screw insertion depth, spondylolisthesis reduction rate, and disc height restoration rate. A change in SLL ≥ 4° indicated increased segmental lumbar lordosis (ISLL), and unincreased segmental lumbar lordosis (UISLL) < 4°. Propensity score matching was employed for a 1:1 match between ISLL and UISLL patients based on age, gender, body mass index, smoking status, and osteoporosis condition.

RESULTS

A total of 192 patients with an average follow-up of 20.9 months were enrolled. Compared to UISLL patients, ISLL patients had significantly lower pre-op DA (6.78° vs. 11.84°), SLL (10.73° vs. 18.24°), LL (42.59° vs. 45.75°), and ADH (10.09 mm vs. 12.21 mm) (all, P < 0.05). ISLL patients were predisposed to more severe intervertebral disc degeneration (P = 0.047) and higher SP (21.30% vs. 19.39%, P = 0.019). The cage was positioned more anteriorly in ISLL patients (67.00% vs. 60.08%, P = 0.000), with more extensive reduction of spondylolisthesis (- 73.70% vs. - 56.16%, P = 0.000) and higher restoration of ADH (33.34% vs. 8.11%, P = 0.000). Multivariate regression showed that lower pre-op SLL (OR 0.750, P = 0.000), more anterior cage position (OR 1.269, P = 0.000), and a greater spondylolisthesis reduction rate (OR 0.965, P = 0.000) significantly impacted SLL restoration.

CONCLUSIONS

Pre-op SLL, cage position, and spondylolisthesis reduction rate were identified as significant predictors of SLL restoration after LFS for DLS. Surgeons are advised to meticulously select patients based on pre-op SLL and strive to position the cage more anteriorly while minimizing spondylolisthesis to maximize SLL restoration.

Developing Mixed-Effects Models to Compare the Predictive Ability of Various Comorbidity Indices in a Contemporary Cohort of Patients Undergoing Lumbar Fusion

BACKGROUND AND OBJECTIVE

As incidence of operative spinal pathology continues to grow, so do the rates of lumbar spinal fusion procedures. Comorbidity indices can be used preoperatively to predict potential complications. However, there is a paucity of research defining the optimal comorbidity indices in patients undergoing spinal fusion surgery. We aimed to use modeling strategies to evaluate the predictive validity of various comorbidity indices and combinations thereof.

METHODS

Patients who underwent spinal fusion were queried using data from the Nationwide Readmissions Database for the years 2016 through 2019. Using comorbidity indices as predictor variables, receiver operating characteristic curves were developed for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 30-day readmission.

RESULTS

A total of 750 183 patients were included. Nonroutine discharges occurred in 161 077 (21.5%) patients. The adjusted all-payer cost for the procedure was $37 616.97 ± $27 408.86 (top quartile: $45 409.20), and the length of stay was 4.1 ± 4.4 days (top quartile: 8.1 days). By comparing receiver operating characteristics of various models, it was found that models using Frailty + Elixhauser Comorbidity Index (ECI) as the primary predictor performed better than other models with statistically significant P -values on post hoc testing. However, for prediction of mortality, the model using Frailty + ECI was not better than the model using ECI alone ( P = .23), and for prediction of all-payer cost, the ECI model outperformed the models using frailty alone ( P < .0001) and the model using Frailty + ECI ( P < .0001).

CONCLUSION

This investigation is the first to use big data and modeling strategies to delineate the relative predictive utility of the ECI and Johns Hopkins Adjusted Clinical Groups comorbidity indices for the prognostication of patients undergoing lumbar fusion surgery. With the knowledge gained from our models, spine surgeons, payers, and hospitals may be able to identify vulnerable patients more effectively within their practice who may require a higher degree of resource utilization.

The effect of perioperative sequential application of multiple doses of tranexamic acid on postoperative blood loss after PLIF: a prospective randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) has been utilized in spinal surgery to effectively reduce intraoperative blood loss (IBL) and allogeneic blood transfusion rates. However, the traditional TXA regimen might last the entire duration of hyperfibrinolysis caused by surgical trauma, resulting in its limited ability to reduce postoperative blood loss (PBL). Therefore, the aim of this study was to investigate the effectiveness of perioperative sequential administration of multiple doses of TXA in reducing PBL in patients who underwent posterior lumbar interbody fusion (PLIF).

METHODS

From October 2022 to June 2023, 231 patients who were diagnosed with lumbar degenerative disease and scheduled to undergo PLIF were prospectively enrolled in the present study. The patients were randomly divided into three groups. Moreover, all patients received an intravenous injection of TXA at a dose of 15 mg/kg 15 min before the surgical skin incision. Patients in Group A received a placebo of normal saline after surgery, while patients in Group B received three additional intravenous injections of TXA at a dose of 15 mg/kg every 24 h. Patients in Group C received three additional intravenous injections of TXA at a dose of 15 mg/kg every 5 h. The primary outcome measure was PBL. In addition, this study assessed total blood loss (TBL), IBL, routine blood parameters, liver and kidney function, coagulation parameters, fibrinolysis indexes, inflammatory indicators, drainage tube removal time (DRT), length of hospital stay (LOS), blood transfusion rate, and incidence of complications for all subjects.

RESULTS

The PBL, TBL, DRT, and LOS of Group B and Group C were significantly lower than those of Group A ( P <0.05). The level of D-dimer (D-D) in Group C was significantly lower than that in Group A on the first day after the operation ( P =0.002), and that in Group B was significantly lower than that in Group A on the third day after the operation ( P =0.003). The interleukin-6 levels between the three groups from 1 to 5 days after the operation were in the order of Group A > Group B > Group C. No serious complications were observed in any patient. The results of multiple stepwise linear regression analysis revealed that PBL was positively correlated with incision length, IBL, smoking history, history of hypertension, preoperative fibrinogen degradation product level, and blood transfusion. It was negatively correlated with preoperative levels of fibrinogen, red blood cells, blood urea nitrogen, and age. Compared to female patients, male patients had an increased risk of PBL. Finally, the incidence of PBL was predicted.

CONCLUSIONS

Sequential application of multiple doses of TXA during the perioperative period could safely and effectively reduce PBL and TBL, shorten DRT and LOS, reduce postoperative D-D generation, and reduce the postoperative inflammatory response. In addition, this study provided a novel prediction model for PBL in patients undergoing PLIF.

Muscle activity and rehabilitation in spinal stenosis (MARSS) after conservative therapy and surgical decompression with or without fusion: Protocol for a partially randomized patient preference trial on rehabilitation timing

Background

Patients affected by lumbar spinal stenosis (LSS) suffer from a multifactorial degeneration of the lumbar spine resulting in narrowing of the neuroforamina and spinal canal, leading to various functional limitations. It remains unclear whether LSS patients after surgery would benefit from early post-operative rehabilitation, or if a delayed rehabilitation would be more advantageous. The purpose of this partially randomized patient preference trial is to evaluate the impact of post-operative rehabilitation timing as well as surgical intervention type on psychometric properties and functional outcomes in patients with LSS.

Methods

Data for this patient preference trial are collected before and after surgical (decompression only or decompression and fusion) and rehabilitative interventions as well as six, 12 and 24 months after completing rehabilitation. The study participants are patients diagnosed with LSS who are at least 18 years old. After a medical check-up, participants will complete patient-reported outcome measures (PAREMO-20, SIBAR, FREM-8, SF-12, SFI, ODI) and different functional assessments (functional reach test, loaded reach test, handgrip strength, standing balance control, 6-min walk test).

Ethics and dissemination

The results of this study will be published through peer-reviewed publications and scientific contributions at national and international conferences. This research has been approved by the Institutional Review Board of Martin Luther University Halle-Wittenberg (reference number: 2022-128).

Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis

BACKGROUND

Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis.

PURPOSE

Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS).

METHODS

Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment.

RESULTS

The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models.

CONCLUSION

Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.

Recovery pattern after decompression of central lumbar spinal stenosis: a prospective observational cohort study

BACKGROUND

Detailed preoperative information is associated with superior outcomes. We aimed to describe the recovery pattern after decompression of central lumbar spinal stenosis (CLSS).

METHODS

50 patients aged 51-85 years who underwent decompression without fusion due to CLSS were followed from before to after surgery (post-op day 1, 7, and 14). Back and leg pain were evaluated using the Numeric Rating Scale (NRS; 0 = no pain 0, 10 = worst pain) and quality of life using the EuroQol-5D index (0 = death, 1 = best), and EQ-5D-visual analogue scale (VAS; 0 = worst, 100 = best).

RESULTS

NRS leg pain was reduced from preoperative to first postoperative day by 5.2 (6.1, 4.3) (mean (95%CI)], and NRS back pain from postoperative day 1-7 by 0.6 (1.2, 0.03) and from day 7 to 14 by 0.7 (1.3, 0.2)]. In contrast, EQ-5D index increased from preoperative to first postoperative day by 0.09 (0.06, 0.13) and from day 1 to 7 by 0.05 (0.02,0.08), and EQ-5D VAS from preoperative to first postoperative day by 13.7 (9.1, 18.3) and from day 1 to 7 by 6.0 (2.0, 10.0). After two weeks, 51% of the patients had improved above the minimal clinically important difference (MCID) in back pain and 71% in leg pain.

CONCLUSIONS

Patients scheduled for decompression due to CLSS should be informed that improvement in leg pain and quality of life in general can be expected within one day of surgery, that quality of life improves a little further in the first postoperative week, and that back pain improves in the first 2 postoperative weeks. In most patients, decompression without fusion due to CLSS seems to achieve clinically relevant improvement within 2 weeks.

Lateral-PLIF for spinal arthrodesis: concept, technique, results, complications, and outcomes

BACKGROUND

Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients.

METHODS

All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18 years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2 years) questionnaires and phone interviews (4 years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1 year) were collected.

RESULTS

One hundred four patients were selected for the final analysis. The median age was 58 years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812 m ± 543 m to 3443 m ± 712 m (p < 0.001). Complications included dural tear (6.7%), infection/wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration.

CONCLUSIONS

Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.

How Does the Slump Sitting Radiograph Increase Proportion of Segmental Instability and Kyphotic Alignment of Lumbar Degenerative Spondylolisthesis?

OBJECTIVE

Clinical and radiographic degenerative spondylolisthesis (CARDS) classification was proposed to differentiate homogenous lumbar degenerative spondylolisthesis (LDS) subgroups. The sitting radiograph exhibited lumbar malalignment with maximum lumbar kyphosis, intervertebral kyphosis, and spondylolisthesis.This study aimed to assess the sitting radiograph for distribution of clinical and radiographic degenerative spondylolisthesis classification, and to elucidate its significance for exhibiting kyphotic alignment (CARDS type D) and segmental instability.

METHODS

A cohort of 101 patients with symptomatic lumbar degenerative spondylolisthesis (LDS) between September 2018 and December 2020 were recruited. The distribution and relibility of CARDS classification with or without sitting radiograph was assessed. The translational and angular range of motion and segmental instability was also evaluated. Univariate analysis of variance was used for multiple groups, and the least significant difference for two groups. Kappa consistency test of intrarater and interrater was evaluated for CARDS classification with or without sitting radiograph. Chi-square test was used to compare paried categorical data.

RESULTS

Utility of sitting radiographs for CARDS classification revealed higher percentage of type D than that without the sitting radiograph (p < 0.001). The sitting radiograph revealed a larger slip distance than the flexion radiograph (p = 0.003), as well as a lower slip angle than flexion radiograph (p < 0.001). The sitting-supine modality demonstrated the largest translational range of motion compared to the sitting-extension (p < 0.001) and flexion-extension modalities (p < 0.001). The sitting-supine modality showed larger angular range of motion than the flexion-extension modality (p < 0.001). The percentage of flexion, extension, upright, supine, and sitting radiograph to identify translational instability was higher than that without sitting radiograph (p < 0.001), as well as taking angular motion ≥10° as an additional criterion for segmental instability (p < 0.001).

CONCLUSION

The CARDS classification was reliable for LDS. The sitting radiograph showed maximal slip distance and kyphotic slip angle. Application of the sitting radiograph was necessary for evaluating segmental instability and kyphotic alignment of LDS.

Resolution of Radiculopathy Following Indirect Versus Direct Decompression in Single Level Lumbar Fusion

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To evaluate resolution of radiculopathy in one-level lumbar fusion with indirect or direct decompression techniques.

METHODS

Patients ≥18 years of age with preoperative radiculopathy undergoing single-level lumbar fusion with up to 2-year follow-up were grouped by indirect and direct decompression. Direct decompression (DD) group included ALIF and LLIF with posterior DD procedure as well as all TLIF. Indirect decompression (ID) group included ALIF and LLIF without posterior DD procedure. Propensity score matching was used to control for intergroup differences in age. Intergroup outcomes were compared using means comparison tests. Logistic regressions were used to correlate decompression type with symptom resolution over time. Significance set at P < .05.

RESULTS

116 patients were included: 58 direct decompression (DD) (mean 53.9y, 67.2% female) and 58 indirect decompression (ID) (mean 54.6y, 61.4% female). DD patients experienced greater blood loss than ID. Additionally, DD patients were 4.7 times more likely than ID patients to experience full resolution of radiculopathy at 3 months post-op. By 6 months, DD patients demonstrated larger reductions in VAS score. With regard to motor function, DD patients had improved motor score associated with the L5 dermatome at 6 months relative to ID patients.

CONCLUSIONS

Direct decompression was associated with greater resolution of radiculopathy in the near post-operative term, with no differences at long term follow-up when compared with indirect decompression. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms.

Outcomes in Lumbar Fusion Patients Stratified by the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) Classification System

Background and objective The Meyerding classification system remains the most common classification system for spondylolisthesis based on the percentages of vertebral translation. However, the majority of patients with degenerative disease fall into Grade 1, limiting its utility in this subset of patients. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system provides a simple radiographic framework for classifying degenerative lumbar spondylolisthesis (DLS) patients by incorporating disc height, kyphosis, and anterior translation. The purpose of this study was to evaluate how clinical characteristics, treatments, and outcomes vary across different CARDS groups in patients undergoing one- or two-level lumbar fusion for DLS. Methods The patients were classified into one of the following four CARDS groups - Type A: advanced disc space collapse with no evidence of kyphosis; Type B: partially preserved disc space with less than 5.0 mm of translation; Type C: partially preserved disc space with greater than 5.0 mm of translation; and Type D: kyphotic alignment. Univariate analyses were performed to compare demographics, symptoms, clinical outcomes, and Patient-Reported Outcomes Measurement Information System (PROMIS) physical (PH) and mental health (MH) scores across groups. Results Ninety-one patients were included in the study. Based on the CARDS classification, there were three (3%) Type A patients, 25 (28%) Type B, 58 (64%) Type C, and five (5%) Type D. No significant differences in baseline demographics, symptom duration, or PROMIS scores were observed across groups. Interbody utilization varied, ranging from 19% in CARDS C (n=11) to 60% in CARDS B (n=15) and D (n=3) patients (p=0.005). Thirty-day clinical outcomes were similar across groups. At an average follow-up of 8.9 months, improvements in PROMIS PH and MH scores and rates of clinically significant improvement were similar across groups. Conclusions Based on our findings, patients undergoing lumbar fusion for DLS present with similar demographic and clinical characteristics and experience similar clinical and patient-reported outcomes when stratified using the CARDS classification system. Posterolateral fusion (PLF) can be effective for various radiographic presentations of DLS. Further research is warranted to assess the utility of CARDS in preoperative planning.

Factors influencing slippage after microsurgical single level lumbar spinal decompression surgery - Are the psoas and multifidus muscles involved?

PURPOSE

Patients with lumbar spinal stenosis (LSS) require microsurgical decompression (MSD) surgery; however, MSD is often associated with postoperative instability at the operated level. Paraspinal muscles support the spinal column; lately, paraspinal volume has been used as a good indicator of sarcopenia. This study aimed to determine preoperative radiological factors, including paraspinal muscle volume, associated with postoperative slippage progression after MSD in LSS patients.

METHODS

Patients undergoing single-level (L3/4 or L4/5) MSD for symptomatic LSS and followed-up for ≥ 5 years in our institute were reviewed retrospectively to measure preoperative imaging parameters focused on the operated level. Paraspinal muscle volumes (psoas muscle index [PMI] and multifidus muscle index [MFMI]) defined using the total cross-sectional area of each muscle/L3 vertebral body area in the preoperative lumbar axial CT) were calculated. Postoperative slippage in the form of static translation (ST) ≥ 2 mm was assessed on the last follow-up X-ray.

RESULTS

We included 95 patients with average age and follow-up periods of 69 ± 8.2 years and 7.51 ± 2.58 years, respectively. PMI and MFMI were significantly correlated with age and significantly larger in male patients. Female sex, preoperative ST, dynamic translation, sagittal rotation angle, facet angle, pelvic incidence, lumbar lordosis, and PMI were correlated with long-term postoperative worsening of ST. However, as per multivariate analysis, no independent factor was associated with postoperative slippage progression.

CONCLUSION

Lower preoperative psoas muscle volume in LSS patients is an important predictive factor of postoperative slippage progression at the operated level after MSD. The predictors for postoperative slippage progression are multifactorial; however, a well-structured postoperative exercise regimen involving psoas muscle strengthening may be beneficial in LSS patients after MSD.

The clinical effect of unilateral decompressive laminectomy plus fusion with unilateral biportal endoscopic technique for single level lumbar spinal stenosis

PURPOSE

This study aimed to compare and analyze the effectiveness of unilateral biportal endoscopic (UBE) decompressive laminectomy plus fusion and microscope-assisted open decompressive laminectomy plus fusion.

METHODS

A total of 143 patients with lumbar spinal stenosis were enrolled in this study between March 2020 and February 2021 with a minimum 2 years follow-up visit to our hospital. Sixty-five patients underwent the unilateral biportal endoscopic technique and were assigned to the UBE group, and the remaining 78 patients with microscope assistant were assigned to the Microscope group. The baseline characteristics, clinical outcomes, and radiological data were retrospectively collected and analyzed, as well as Clinical outcomes, radiological data and complications.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics (P > 0.05). The UBE group was demonstrated to be significantly superior in CRP, drainage, blood loss, treatment cost and Hospital stay than the Microscope group (P < 0.05), whereas a significant longer operation time was observed (P < 0.05). The VAS-B, ODI, and JOA-L scores of the UBE group at 1 year follow-up were significantly greater than those of the Microscope group (P < 0.05). Regarding radiological data, there were no significant differences in the section area of the spinal canal and fusion grade between the two groups (P > 0.05).

CONCLUSION

In view of the satisfactory clinical outcomes of patients and notable decompression at the stenosed segment, UBE is a feasible, minimally invasive technique for single level lumbar canal stenosis.

Invasiveness of decompression surgery affects modeled lumbar spine kinetics in patients with degenerative spondylolisthesis

Introduction: The surgical treatment of degenerative spondylolisthesis with accompanying spinal stenosis focuses mainly on decompression of the spinal canal with or without additional fusion by means of a dorsal spondylodesis. Currently, one main decision criterion for additional fusion is the presence of instability in flexion and extension X-rays. In cases of mild and stable spondylolisthesis, the optimal treatment remains a subject of ongoing debate. There exist different opinions on whether performing a fusion directly together with decompression has a potential benefit for patients or constitutes overtreatment. As X-ray images do not provide any information about internal biomechanical forces, computer simulation of individual patients might be a tool to gain a set of new decision criteria for those cases. Methods: To evaluate the biomechanical effects resulting from different decompression techniques, we developed a lumbar spine model using forward dynamic-based multibody simulation (FD_MBS). Preoperative CT data of 15 patients with degenerative spondylolisthesis at the level L4/L5 who underwent spinal decompression were identified retrospectively. Based on the segmented vertebrae, 15 individualized models were built. To establish a reference for comparison, we simulated a standardized flexion movement (intact) for each model. Subsequently, we performed virtual unilateral and bilateral interlaminar fenestration (uILF, bILF) and laminectomy (LAM) by removing the respective ligaments in each model. Afterward, the standardized flexion movement was simulated again for each case and decompression method, allowing us to compare the outcomes with the reference. This comprehensive approach enables us to assess the biomechanical implications of different surgical approaches and gain valuable insights into their effects on lumbar spine functionality. Results: Our findings reveal significant changes in the biomechanics of vertebrae and intervertebral discs (IVDs) as a result of different decompression techniques. As the invasiveness of decompression increases, the moment transmitted on the vertebrae significantly rises, following the sequence intact ➝ uILF ➝ bILF ➝ LAM. Conversely, we observed a reduction in anterior-posterior shear forces within the IVDs at the levels L3/L4 and L4/L5 following LAM. Conclusion: Our findings showed that it was feasible to forecast lumbar spine kinematics after three distinct decompression methods, which might be helpful in future clinical applications.

Determining Differences in Perioperative Functional Mobility Patterns in Lumbar Decompression Versus Fusion Patients Using Smartphone Activity Data

BACKGROUND AND OBJECTIVES

Smartphone activity data recorded through high-fidelity accelerometry can provide accurate postoperative assessments of patient mobility. The "big data" available through smartphones allows for advanced analyses, yielding insight into patient well-being. This study compared rate of change in functional activity data between lumbar fusion (LF) and lumbar decompression (LD) patients to determine preoperative and postoperative course differences.

METHODS

Twenty-three LF and 18 LD patients were retrospectively included. Activity data (steps per day) recorded in Apple Health, encompassing over 70 000 perioperative data points, was classified into 6 temporal epochs representing distinct functional states, including acute preoperative decline, immediate postoperative recovery, and postoperative decline. The daily rate of change of each patient's step counts was calculated for each perioperative epoch.

RESULTS

Patients undergoing LF demonstrated steeper preoperative declines than LD patients based on the first derivative of step count data (P = .045). In the surgical recovery phase, LF patients had slower recoveries (P = .041), and LF patients experienced steeper postoperative secondary declines than LD patients did (P = .010). The rate of change of steps per day demonstrated varying perioperative trajectories that were not explained by differences in age, comorbidities, or levels operated.

CONCLUSION

Patients undergoing LF and LD have distinct perioperative activity profiles characterized by the rate of change in the patient daily steps. Daily steps and their rate of change is thus a valuable metric in phenotyping patients and understanding their postsurgical outcomes. Prospective studies are needed to expand upon these data and establish causal links between preoperative patient mobility, patient characteristics, and postoperative functional outcomes.

Implications of Preoperative Depression for Lumbar Spine Surgery Outcomes: A Systematic Review and Meta-Analysis

Importance

Comorbid depression is common among patients with degenerative lumbar spine disease. Although a well-researched topic, the evidence of the role of depression in spine surgery outcomes remains inconclusive.

Objective

To investigate the association between preoperative depression and patient-reported outcome measures (PROMs) after lumbar spine surgery.

Data Sources

A systematic search of PubMed, Cochrane Database of Systematic Reviews, Embase, Scopus, PsychInfo, Web of Science, and ClinicalTrials.gov was performed from database inception to September 14, 2023.

Study Selection

Included studies involved adults undergoing lumbar spine surgery and compared PROMs in patients with vs those without depression. Studies evaluating the correlation between preoperative depression and disease severity were also included.

Data Extraction and Synthesis

All data were independently extracted by 2 authors and independently verified by a third author. Study quality was assessed using Newcastle-Ottawa Scale. Random-effects meta-analysis was used to synthesize data, and I2 was used to assess heterogeneity. Metaregression was performed to identify factors explaining the heterogeneity.

Main Outcomes and Measures

The primary outcome was the standardized mean difference (SMD) of change from preoperative baseline to postoperative follow-up in PROMs of disability, pain, and physical function for patients with vs without depression. Secondary outcomes were preoperative and postoperative differences in absolute disease severity for these 2 patient populations.

Results

Of the 8459 articles identified, 44 were included in the analysis. These studies involved 21 452 patients with a mean (SD) age of 57 (8) years and included 11 747 females (55%). Among these studies, the median (range) follow-up duration was 12 (6-120) months. The pooled estimates of disability, pain, and physical function showed that patients with depression experienced a greater magnitude of improvement compared with patients without depression, but this difference was not significant (SMD, 0.04 [95% CI, -0.02 to 0.10]; I2 = 75%; P = .21). Nonetheless, patients with depression presented with worse preoperative disease severity in disability, pain, and physical function (SMD, -0.52 [95% CI, -0.62 to -0.41]; I2 = 89%; P < .001), which remained worse postoperatively (SMD, -0.52 [95% CI, -0.75 to -0.28]; I2 = 98%; P < .001). There was no significant correlation between depression severity and the primary outcome. A multivariable metaregression analysis suggested that age, sex (male to female ratio), percentage of comorbidities, and follow-up attrition were significant sources of variance.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggested that, although patients with depression had worse disease severity both before and after surgery compared with patients without depression, they had significant potential for recovery in disability, pain, and physical function. Further investigations are needed to examine the association between spine-related disability and depression as well as the role of perioperative mental health treatments.

Management of Low and High Grades Spondylolisthesis

Spondylolisthesis is defined as the displacement or misalignment of the vertebral bodies one on top of the other. It comes from the Greek spondlylos, which means vertebra, and olisthesis, which means sliding on a slope. The nomenclature used to refer to spondylolisthesis consists of the following elements: vertebral segment (vertebrae involved), degree of sliding of one vertebral body over the other, the position of the upper vertebral body with respect to the lower one (anterolisthesis/retrolisthesis), and finally the etiology [1].

20-year Inflation-Adjusted Medicare Reimbursements (Years: 2000-2020) For Common Lumbar and Cervical Degenerative Disc Disease Procedures

OBJECTIVE

Reimbursement trends for common procedures have persistently declined over the past 2 decades. Spinal instrumentational and fusion procedures are increasingly utilized and have increased in clinical complexity, yet longitudinal inflation-adjusted data for Medicare reimbursements of these procedures have not been evaluated.

METHODS

The Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements for the 5 most common spinal procedures and associated instrumentations from 2000-2020. Current Procedural Terminology (CPT) codes include 22551, 22600, 22633, 63030, and 63047 as well as instrumentation CPT codes 22840 and 22842-6. The nominal values were adjusted for inflation according to the latest consumer price index (U.S. Bureau of Labor Statistics; reported as 2020 USD) and used to calculate average annual percent changes and compound annual growth rates (CAGRs) in reimbursements.

RESULTS

After inflation adjustment, the physician fee reimbursement decreased by 11.05% ± 8.46% (mean ± s.d., from $2,009.89 in 2011 to $1,787.85 in 2020) for anterior cervical discectomy and fusion (ACDF), 28.38% ± 8.42% (from $1,889.38 in 2000 to $1,353.14 in 2020) for posterior cervical fusion, 7.85% ± 8.20% (from $2,111.20 in 2012 to $1,945.49 in 2020) for transforaminal lumbar interbody fusion (TLIF), 28.17% ± 13.88% (from $1,421.78 in 2000 to $1,021.22 in 2020) for lower back disc surgery, and 31.88% ± 8.22% (from $1,700.38 in 2000 to $1,158.25 in 2020) for lumbar laminectomy. Instrumentation reimbursements showed an average decrease of 33.43% ± 8.4% over this period. Average CAGR was -1.7% ± .41% for procedures and -2.02% ± .14% for instrumentation.

CONCLUSION

Our analysis reveals a persistent decline in reimbursement rates of the most common spine procedures and instrumentation since the year 2000. If unaddressed, this trend can serve as a substantial disincentive for physicians to perform these procedures and can significantly limit access to spinal care at the population level.

Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis

BACKGROUND

In this study we proposed a new strategy to measure cost-effectiveness of second opinion program on spine surgery, using as measure of effectiveness the minimal important change (MIC) in the quality of life reported by patients, including the satisfaction questionnaire regarding the treatment and direct medical costs.

METHODS

Retrospective analysis of patients with prior indication for spine surgery included in a second opinion program during May 2011 to May 2019. Treatment costs and outcomes were compared considering each patients' recommended treatment before and after the second opinion. Costs were measured under the perspective of the hospital, including hospital stay, surgical room, physician and staff fees and other costs related to hospitalization when surgery was performed and physiotherapy or injection costs when a conservative treatment was recommended. Reoperation costs were also included. For comparison analysis, we used data based on our clinical practice, using data from patients who underwent the same type of surgical procedure as recommended by the first referral. The measure of effectiveness was the percentage of patients who achieved the MIC in quality of life measured by the EQ-5D-3 L 2 years after starting treatment. An incremental cost-effectiveness ratio (ICER) was calculated.

RESULTS

Based upon the assessment of 1,088 patients that completed the entire second opinion process, conservative management was recommended for 662 (60.8%) patients; 49 (4.5%) were recommended to injection and 377 (34.7%) to surgery. Complex spine surgery, as arthrodesis, was recommended by second opinion in only 3.7% of cases. The program resulted in financial savings of -$6,705 per patient associated with appropriate treatment indication, with an incremental effectiveness of 0.077 patients achieving MIC when compared to the first referral, resulting in an ICER of $-87,066 per additional patient achieving the MIC, ranging between $-273,016 and $-41,832.

CONCLUSION

After 2 years of treatment, the second opinion program demonstrated the potential for cost-offsets associated with improved quality of life.

Minimally Invasive Decompression With Noninstrumented Facet Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Stenosis Associated With Grade 1 Lumbar Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective matched cohort study.

SUMMARY OF BACKGROUND DATA

With a growing interest in minimally invasive spine surgery (MIS), the question of which technique is the most advantageous for patients with low-grade degenerative lumbar spondylolisthesis (DLS) still remains unclear.

OBJECTIVE

To compare patient-reported outcomes, perioperative morbidity, and rates of reoperation between MIS decompression with either unilateral noninstrumented facet fusion (MIS-F) or with transforaminal interbody fusion (MIS-T) for grade 1 DLS.

METHODS

Twenty patients who underwent MIS-T and 20 patients with MIS-F were matched based on age, sex, and preoperative ODI, VAS back, and VAS leg. All patients had DLS with at least 4 millimeters of translation on standing radiographs. Exclusion criteria included prior level surgery, multilevel instability, disk impinging on the exiting nerve root, spondylolisthesis from significant facet arthropathy, or foraminal compromise from disk collapse. ODI, VAS back, VAS leg, and patient satisfaction measured by the North American Spine Society questionnaire were tracked at 3, 6, 12, and 24 months postoperatively. Minimum clinically important differences and substantial clinical benefits were calculated.

RESULTS

MIS-F and MIS-T resulted in decreased ODI at 3, 6, and 12 months following the index procedure. Sixty percent of MIS-F and 83% of MIS-T patients reached minimum clinically important difference at 1 year postoperatively; however, using the threshold of 30% ODI reduction from baseline, 67% of MIS-F and 83% MIS-T ( P = 0.25) achieved this goal. Forty-three percent of MIS-F and 59% of MIS-T patients met substantial clinical benefits. Satisfaction at 1 year, measured by a score of 1 or 2 on the North American Spine Society questionnaire, was 64% for MIS-F and 83% for MIS-T.

CONCLUSIONS

MIS-F and MIS-T are effective treatment options for spinal stenosis associated with low-grade DLS. Both techniques result in comparable patient-reported outcomes and satisfaction up to 2 years and have similar long-term reoperation rates. More evidence is required to delineate optimal selection characteristics for MIS-F versus MIS-T.

Lumbar adjacent segment degeneration after spinal fusion surgery: a systematic review and meta-analysis

INTRODUCTION

Adjacent segment degeneration is among the most recognized long-term complications of lumbar surgery for degenerative spine pathologies with a relevant impact in spine surgical and clinical practice. It is reported a incidence of clinical adjacent segment disease between 5-30% of patients undergoing spinal fusion. We aimed to evaluate the main clinical and surgical risk factors for developing adjacent segment disease.

EVIDENCE ACQUISITION

A systematic review and meta-analysis of the pertinent literature was performed, according to PRISMA and PICO guidelines, focusing on clinical and radiological adjacent segment disease. We exclusively included studies reporting demographic and clinical data, and surgical details published from 30 September 2015 to 30 September 2020. The effect of considered risk factors on the presence of adjacent segment disease was explored with a random-effects model.

EVIDENCE SYNTHESIS

A total of 15 scientific publications, corresponding to 6253 patients, met the inclusion criteria for the qualitative and quantitative analysis. 720 of the patients developed a clinical and/or radiological adjacent syndrome disease, and 473 have been surgically managed. Ten articles qualified for the comparative geographical analysis. Advanced age and obesity are relevant risk factors for developing lumbar adjacent segment degeneration. Our data also reported a higher prevalence of adjacent segment degeneration in Western populations than in Eastern populations. The interbody fusion has a protective role toward lumbar adjacent segment degeneration.

CONCLUSIONS

This study highlighted multifactorial issues regarding adjacent segment disease: clinical, anatomical, biomechanical, and radiological features. In view of increasing life expectancy and spinal surgery procedures, extensive multicenter studies will be needed to define the correct management of the adjacent segment disease.

Radiographic and Clinical Outcomes After Stand-Alone Anterior Lumbar Interbody Fusion for Symptomatic L5-S1 Retrolisthesis

BACKGROUND AND OBJECTIVES

Degenerative lumbar spondylolisthesis is associated with significant pain and disability. The literature on the treatment options and clinical outcomes for lumbar anterolisthesis is robust, but very few reports specifically evaluate lumbar retrolisthesis. This study investigated surgical outcomes for symptomatic L5-S1 retrolisthesis treated with stand-alone L5-S1 anterior lumbar interbody fusion (ALIF).

METHODS

All patients with symptomatic L5-S1 retrolisthesis treated with stand-alone L5-S1 ALIF at a single institution over a 7-year period were identified. Exhaustive nonoperative management had failed for all patients. Patients with previous lumbar fusion were excluded. Preoperative and postoperative radiographic images and patient-reported outcome measures for 20 patients (14 males and 6 females; mean [SD] age, 50.3 [13.7] years) were analyzed.

RESULTS

The mean (SD) follow-up was 43.0 (23.7) months (range, 12.1-102.5 months). Patients experienced postoperative improvements in L5-S1 retrolisthesis (P = .048), L5-S1 disk height and angle (P < .001), L5 foraminal height (P < .001), L5-S1 lordosis (P < .001), and lumbar lordosis (P = .01). There were no significant changes in spinopelvic parameters. At the most recent follow-up, minimal clinically important differences in Oswestry Disability Index score, 36-Item Short-Form Survey (SF-36), and numerical rating scale score for leg pain were achieved in 11 of 20 (55%), 7 of 14 (50%), and 7 of 13 (54%) patients, respectively. All patients demonstrated fusion with no graft subsidence at up to 32 months. No patient experienced intraoperative complications, was readmitted, or required a subsequent posterior decompression or fusion because of refractory symptoms.

CONCLUSION

In our cohort, stand-alone L5-S1 ALIF was associated with radiographic and clinical improvement in patients with symptomatic L5-S1 retrolisthesis.

Preoperative factors affecting the two-year postoperative patient-reported outcome in single-level lumbar grade I degenerative spondylolisthesis

Background

The choice of operative method for lumbar spinal stenosis with Meyerding grade I degenerative spondylolisthesis remains controversial. The purpose of this study was to identify the preoperative factors affecting the 2-year postoperative patient-reported outcome in Meyerding grade I degenerative spondylolisthesis.

Methods

Seventy-two consecutive patients who had minimally invasive decompression alone (D group; 28) or with fusion (DF group; 44) were enrolled. The parameters investigated were the Japanese Orthopaedic Association back pain evaluation questionnaire as patient-reported assessment, and L4 slippage (L4S), lumbar lordosis (LL), and lumbar axis sacral distance (LASD) as an index of sagittal alignment for radiological evaluation. Data collected prospectively at 2 years postoperatively were examined by statistical analysis.

Results

Sixty-two cases (D group; 25, DF group; 37) were finally evaluated. In multiple logistic regression analysis, preoperative L4S and LASD were extracted as significant preoperative factors affecting the 2-year postoperative outcome. Patients with preoperative L4S of 6 mm or more have a lower rate of improvement in lumbar spine dysfunction due to low back pain (risk ratio=0.188, p=.043). Patients with a preoperative LASD of 30 mm or more have a higher rate of improvement in lumbar dysfunction due to low back pain (risk ratio=11.48, p=.021). The results of multiple logistic analysis by operative method showed that there was a higher rate of improvement in lumbar spine dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more in DF group (risk ratio=172.028, p=.01).

Conclusions

Preoperative L4S and LASD were extracted as significant preoperative factors affecting patient-reported outcomes at 2 years postoperatively. Multiple logistic analyses by the operative method suggested that DF may be advantageous in improving lumbar dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more.

The Norwegian degenerative spondylolisthesis and spinal stenosis (NORDSTEN) study: study overview, organization structure and study population

PURPOSE

To provide an overview of the The Norwegian Degenerative spondylolisthesis and spinal stenosis (NORDSTEN)-study and the organizational structure, and to evaluate the study population.

METHODS

The NORDSTEN is a multicentre study with 10 year follow-up, conducted at 18 public hospitals. NORDSTEN includes three studies: (1) The randomized spinal stenosis trial comparing the impact of three different decompression techniques; (2) the randomized degenerative spondylolisthesis trial investigating whether decompression surgery alone is as good as decompression with instrumented fusion; (3) the observational cohort tracking the natural course of LSS in patients without planned surgical treatment. A range of clinical and radiological data are collected at defined time points. To administer, guide, monitor and assist the surgical units and the researchers involved, the NORDSTEN national project organization was established. Corresponding clinical data from the Norwegian Registry for Spine Surgery (NORspine) were used to assess if the randomized NORDSTEN-population at baseline was representative for LSS patients treated in routine surgical practice.

RESULTS

A total of 988 LSS patients with or without spondylolistheses were included from 2014 to 2018. The clinical trials did not find any difference in the efficacy of the surgical methods evaluated. The NORDSTEN patients were similar to those being consecutively operated at the same hospitals and reported to the NORspine during the same time period.

CONCLUSION

The NORDSTEN study provides opportunity to investigate clinical course of LSS with or without surgical interventions. The NORDSTEN-study population were similar to LSS patients treated in routine surgical practice, supporting the external validity of previously published results.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018.

Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications

BACKGROUND

Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently.

AIM

To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature.

METHODS

On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.

RESULTS

A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%.

CONCLUSION

Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.

Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study

BACKGROUND AND OBJECTIVES

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date.

METHODS

A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay.

RESULTS

A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms-8.2%, new lower extremity weakness-5.8%, wound infection-1.4%, cage subsidence-0.8%, psoas hematoma-0.5%, small bowel obstruction and ischemia-0.3%, and 90-day readmission-1.9%.

CONCLUSION

In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide to surgical technique selection

BACKGROUND CONTEXT

The role of fusion in degenerative spondylolisthesis (DS) is controversial. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was developed to assist surgeons in surgical technique selection based on individual patient characteristics. This system has not been clinically validated as a guide to surgical technique selection.

PURPOSE

The purpose of this study was to determine if outcomes vary with different surgical techniques across the CARDS categories.

STUDY DESIGN/SETTING

Prospective cohort study performed at one Swiss and one American spine center.

PATIENT SAMPLE

Five hundred eight patients with DS undergoing surgical treatment.

OUTCOME MEASURES

Core Outcomes Measure Index (COMI) at 3 months and 12 months postoperatively.

METHODS

Patients undergoing surgery for DS were enrolled at 2 institutions and classified according to the CARDS system using dynamic radiographs. The Core Outcome Measure Index (COMI) was completed preoperatively, and 3 and 12 months postoperatively. Surgical technique was classified as uninstrumented (decompression alone or decompression with uninstrumented fusion) or instrumented (decompression with pedicle screw instrumentation with or without interbody fusion). Unadjusted analyses and mixed effect models compared COMI scores between the two surgery technique groups (uninstrumented vs instrumented), stratified by CARDS category over time. Reoperation rates were also compared between the surgery technique groups stratified by CARDS category. Partial funding was given through NASS grant for clinical research.

RESULTS

Five hundred five out of 508 patients enrolled in the study had sufficient data to be classified according to CARDS. Seven percent were classified as CARDS A, 28% as CARDS B, 48% as CARDS C, and 17% as CARDS D (CARDS A most "stable," CARDS D least "stable"). One hundred and thirty-three patients (26%) underwent decompression alone, 30 (6%) underwent decompression and uninstrumented fusion, 42 (8%) underwent decompression and posterolateral instrumented fusion, and 303 (60%) underwent decompression with posterolateral and interbody instrumented fusion. Patients in the least "stable" categories tended to be less likely to be treated with an uninstrumented technique (CARDS D 19% vs 32% for the other categories, p=.10). There were no significant differences in 3 or 12-month COMI scores between surgical technique groups stratified by CARDS category in the unadjusted or adjusted analyses. In the unadjusted analyses, there was a trend towards less improvement in 12-month COMI change score in the CARDS D patients in the uninstrumented group compared to the instrumented group (-2.7 vs -4.1, p=.10). Reoperation rates were not significantly different between the surgical technique groups stratified by CARDS category.

CONCLUSIONS

In general, outcomes for uninstrumented and instrumented surgical techniques were similar across the CARDS categories. Surgeons likely took factors included in CARDS into account during surgical technique selection. This resulted in a low number of CARDS D (n=15) patients being treated with uninstrumented techniques, which limited the statistical power of this analysis. As such, this study does not validate CARDS as a useful classification system for surgical technique selection in DS.

Degenerative L4-L5 spondylolisthesis and stenosis surgery: does over-level flavectomy technique influence clinical outcomes and rates of cranial adjacent segment disease?

BACKGROUND

One of the most dreaded long-term complications related to L4-L5 lumbar arthrodesis is the onset of adjacent segment disease, which most frequently occurs at the cranial level. Few studies have compared the rates of cranial adjacent segment disease (CASD) in patients undergoing lumbar fusion associated with total laminectomy at the same level with those undergoing partial laminectomy. No study has examined the role of selective over-level flavectomy (OLF; i.e., L3-L4).

METHODS

A total of 299 patients undergoing posterolateral arthrodesis (PLA) for L4-L5 degenerative spondylolisthesis were retrospectively analyzed with a 5-year follow-up. 148 patients underwent PLA + L4-L5 flavectomy + L4 partial laminectomy (control group), while 151 underwent PLA + L4-L5 flavectomy + total L4 laminectomy + L3-L4 flavectomy (OLF group). Rates of reoperations due to CASD were examined utilizing Cox proportional hazard models, while clinical improvement at follow-up (measured in ODI) was analyzed using generalized linear models (GLMs). Adjustments for potential confounders were made (grade of lumbar lordosis, age, sex, BMI, intervertebral disc degeneration, and presurgical cranial spinal stenosis).

RESULTS

At 5 years from the operation, 16 patients (10.8%) in the control group had undergone revision surgery for CASD compared to 5 patients (3.3%) in the OLF group (p = 0.013). Survival analysis and GLM demonstrated that the OLF group had a significantly lower incidence of CASD and presented more favorable clinical outcome. There were no differences in the rate of discal degeneration or the onset of Meyerding's grade I degenerative spondylolisthesis at the adjacent segment. BMI was the only other significant predictor of ODI improvement and of the incidence of CASD.

CONCLUSIONS

In patients with L4-L5 degenerative spondylolisthesis and stenosis, the OLF technique may lower rates of CASD and improve clinical outcomes by preventing cranial spinal stenosis without increasing iatrogenic instability or accelerating intervertebral disc degenerative changes.

Severity of spinal degeneration does not affect the pain reduction under continuous epidural analgesia

PURPOSE

To outline clinical effectiveness of continuous epidural analgesia (CEA) in patients with failed back surgery syndrome (FBSS) or lumbar spinal stenosis (LSS) depending on severity of spinal degeneration.

METHODS

In this retrospective cohort study, all patients with FBSS or LSS who underwent CEA within an inpatient rehabilitation program were evaluated. The pain reduction was measured by VAS on an hourly basis. Substantial pain reduction was defined as a minimal clinically important difference (MCID) > 50%. Severity of spinal degeneration, side effects and patient-specific characteristics were documented.

RESULT

We included a total of 148 patients with 105 patients suffering from FBSS and 48 with LSS. The average pain reduction was - 37.6 ± 19.2 in FBSS and - 38.1 ± 17.8 in LSS group (p < .001 and p < .001, respectively). In the FBSS group, sensory deficits (p = .047) and numbness (p = .002), and in the LSS group, a severe disability measured by ODI (38.2 ± 15.4 vs. 57.3 ± 11.3, p < .001) significantly contributed to a worse outcome. The severity of the spinal degeneration and psychological disorders did not affect the pain reduction in terms of MCID.

CONCLUSIONS

This study provides new evidence about CEA in the treatment of FBSS and LSS. CEA provides a significant pain reduction even under intensified physiotherapeutic exercising in patients with severe spinal degeneration and a broad variety of secondary diagnoses. Neurologic deficits in case of FBSS and severe disability in case of LSS may be risk factors for less favorable outcome.

Progression to fusion after lumbar laminectomy for degenerative lumbar spondylolisthesis: Rate and risk-factors. A national database study

OBJECTIVE

Lumbar laminectomy is often utilized in the treatment of degenerative lumbar spondylolisthesis. Risk factors that contribute to reoperation rates, in particular to progression to fusion, are poorly understood. We aimed to identify rate and risk factors of lumbar fusion surgery following lumbar laminectomy for the treatment of degenerative lumbar spinal spondylolisthesis.

METHODS

Our sample was obtained from the national MarketScan Commercial Claims and Encounters Database. We reviewed patients undergoing lumbar laminectomy for stable degenerative lumbar spondylolisthesis (Grade-1) at one or two levels between January 2007 and December 2016.

RESULTS

A total of 33,681 patients were included. By 2 years after the index operation, 2.48 % of patients had required lumbar fusion surgery. Female sex was associated with lower odds (OR 0.8, 95 %CI 0.7-0.9) of reoperation for fusion. Diabetes (OR 1.2, 95 %CI 1.1-1.4), rheumatoid arthritis (OR 1.5, 95 %CI 1.2-1.7) and clinical presentation with LBP (OR 2.1, 95 %CI 1.6-2.9), lower extremity weakness (OR 1.4, 95 %CI 1.1-1.5), as well as occurrence of a postoperative neurological complications (OR 2.0, 95 %CI 1.1-3.4) increased the odds ratio for requiring fusion surgery within two years after lumbar laminectomy.

CONCLUSION

In this large cross-sectional sample of a national claims database consisting of lumbar laminectomy patients for the treatment of spondylolisthesis, approximately 2.5 % required subsequent lumbar fusion. Several modifiable risk factors for fusion progression were identified, which may guide clinicians in shared decision-making and to help identify patients with elevated post-operative risk providing potential leverage point for prevention.

Quality of Life with Respect to Surgically Treated Vertebral Osteomyelitis and Degenerative Spondylolisthesis

Vertebral osteomyelitis (VO) and degenerative spondylolisthesis (SL) are 2 commonly treated spinal conditions. Therefore, in the presented work, the quality of life after surgical therapy of these 2 entities is compared using established scores.In a monocentric study, all patients with VO and SL were prospectively enrolled using the Spine Tango Registry. Surgical procedures included one- or two-stage fusion of the affected segments. Quality of life was assessed using the Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) at time points t0 (0 months), t1 (12 months), and t2 (24 months). Statistical analysis was performed using SPSS. The level of significance was set at 5%.52 patients with VO and 48 patients with SL were included in the analysis. There were no significant differences in age and gender distribution. The length of stay in the SL group was significantly shorter (p < 0.001). ODI at time t0 was significantly higher in the VO group (p < 0.001), whereas COMI scores did not differ significantly (p = 0.155). At time points t1 and t2, the differences between the VO and SL groups were not significantly different for either the ODI score (p = 0.176; p = 0.250) or the COMI score (p = 0.682; p = 0.640).Postoperative quality of life scores after lumbar fusion surgery in SL and VO are comparable despite different indications and medical conditions. In both groups, similar quality of life with in patient with chronic back pain was achieved. This should be considered for the preoperative assessment, as well as for the indication for surgery in SL.

Surgical treatment of spondylolisthesis by oblique lumbar interbody fusion and transpedicular screw fixation: Comparison between conventional double position versus navigation-assisted single lateral position

BACKGROUND AND OBJECTIVES

Oblique lumbar interbody fusion (OLIF) procedures involve anterior insertion of interbody cage in lateral position. Following OLIF, insertion of pedicle screws and rod system is performed in a prone position (OLIF-con). The location of the cage is important for restoration of lumbar lordosis and indirect decompression. However, inserting the cage at the desired location is difficult without reduction of spondylolisthesis, and reduction after insertion of interbody cage may limit the amount of reduction. Recent introduction of spinal navigation enabled both surgical procedures in one lateral position (OLIF-one). Therefore, reduction of spondylolisthesis can be performed prior to insertion of interbody cage. The objective of this study was to compare the reduction of spondylolisthesis and the placement of cage between OLIF-one and OLIF-con.

METHODS

We retrospectively reviewed 72 consecutive patients with spondylolisthesis for this study; 30 patients underwent OLIF-one and 42 underwent OLIF-con. Spinal navigation system was used for OLIF-one. In OLIF-one, the interbody cage was inserted after reducing spondylolisthesis, whereas in OLIF-con, the cage was inserted before reduction. The following parameters were measured on X-rays: pre- and postoperative spondylolisthesis slippage, reduction degree, and the location of the cage in the disc space.

RESULTS

Both groups showed significant improvement in back and leg pains (p < .05). Transient motor or sensory changes occurred in three patients after OLIF-con and in two patients after OLIF-one. Pre- and postoperative slips were 26.3±7.7% and 6.6±6.2% in OLIF-one, and 23.1±7.0% and 7.4±5.8% in OLIF-con. The reduction of slippage was 74.4±6.3% after OLIF-one and 65.4±5.7% after OLIF-con, with a significant difference between the two groups (p = .04). The cage was located at 34.2±8.9% after OLIF-one and at 42.8±10.3% after OLIF-con, with a significant difference between the two groups (p = .004).

CONCLUSION

Switching the sequence of surgical procedures with OLIF-one facilitated both the reduction of spondylolisthesis and the placement of the cage at the desired location.

Instrumented Versus Uninstrumented Posterolateral Fusion for Lumbar Spondylolisthesis: A Randomized Controlled Trial

BACKGROUND

In Scandinavia, spinal fusion is frequently performed without instrumentation, as use of instrumentation in the elderly can be complicated by poor bone quality and the risk of screw pull-out. However, uninstrumented fusion carries the risk of nonunion. We performed a randomized controlled trial in an attempt to determine if use of instrumentation leads to better outcomes and fusion rates when spinal fusion is performed for degenerative spondylolisthesis in the elderly.

METHODS

This was a randomized, single-center, open-label trial of patients with symptomatic single-level degenerative spondylolisthesis who were assigned 1:1 to decompression and fusion with or without instrumentation after at least 12 weeks of nonoperative treatment had failed. The primary outcome was the change in the Oswestry Disability Index (ODI), and secondary outcomes included fusion rates within 1 year, reoperation rates within 2 years, and changes in the EuroQol-5 Dimension-3 Level (EQ-5D) score.

RESULTS

Fifty-four subjects were randomized to each of the 2 groups, which had similar preoperative demographic and surgical characteristics. We found similar improvements in the ODI (p = 0.791), back pain, leg pain, and quality of life between groups at 1 and 2 years of follow-up. Solid fusion on computed tomography (CT) scans was noted in 94% of the patients in the instrumented group and 31% in the uninstrumented group (p < 0.001). One patient (2%) in the instrumented group and 7 (13%) in the uninstrumented group (p = 0.031) had a reoperation within 2 years after the index surgery.

CONCLUSIONS

We found no difference in patient-reported outcomes when we compared instrumented with uninstrumented fusion in patients with degenerative spondylolisthesis. The uninstrumented group had a significantly higher rate of nonunion and reoperations at 2 years.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Saving Stabilizing Structure Treatment With Bilateral-Contralateral Decompression for Spinal Stenosis in Degenerative Spondylolisthesis Using Unilateral Biportal Endoscopy

OBJECTIVE

This study aimed to evaluate the treatment of spinal stenosis with spondylolisthesis using bilateral-contralateral unilateral biportal endoscopic (UBE) decompression to minimize facet joint damage.

METHODS

We retrospectively evaluated 42 patients with grade 1 spondylolisthesis who underwent bilateral-contralateral UBE decompression between July 2018 and September 2019. To identify segmental instability, static and dynamic images from preoperative and postoperative procedures and final follow-up radiographs were reviewed. Lateral radiograph slippage ratio, sagittal motion, and facet joint preservation were evaluated. Clinical assessments were conducted using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

RESULTS

The average final follow-up period was 26.5 ± 1.3 months. The average preoperative slip percentage was 15.70% ± 5.25%, which worsened to 18.80% ± 5.41% at the final follow-up (p < 0.005). The facet joint preservation rate was 95.6% ± 4.1% on the contralateral side. Improvements in the VAS scores (leg pain: from 7.9 ± 2.2 to 3.1 ± 0.7; p < 0.005; back pain: from 7.2 ± 3.0 to 2.8 ± 1.0; p < 0.005) were observed at the final follow-up. The mean preoperative ODI was 26.19 ± 3.42, which improved to 9.6 ± 1.0 (p < 0.005). Thirteen patients exhibited delayed focal segmental instability following decompression. Despite the absence of symptoms or improvement with conservative treatment in the majority of patients with delayed instability, two patients required fusion surgery to address the instability. Additionally, 2 patients developed facet synovial cysts, while 2 experienced spinous process fractures.

CONCLUSION

Bilateral decompression with a contralateral UBE approach could be an effective and alternative treatment method to reduce instability in spinal stenosis with grade 1 spondylolisthesis.

Minimally Invasive Surgery for Managing Grade IV and V Spondylolisthesis

Surgical treatment of high-grade spondylolisthesis is controversial and aims at restoring the spinopelvic sagittal balance through complete or partial reduction of the listhesis. Nerve decompression and interbody fusion are necessary for patients presenting with neurological deficit, severe pain, lower limb asymmetry, or deformities. We present the case and the results of a patient with high-grade spondylolisthesis, in whom minimally invasive management was performed. A narrative review in this topic is also provided. We performed a literature review of high-grade spondylolisthesis to compare our technique to current surgical alternatives. We included articles from PubMed, Embase, Scopus, Ovid, and Science Direct published between 1963 and 2022 that were written in English, German, and Spanish. The terms used were the following: "high grade spondylolisthesis," "spondyloptosis," "surgical management," "interbody fusion," and "arthrodesis." In all, 485 articles were displayed, from which we filtered 112 by title and abstract. At the end, 75 references were selected for the review. Different interbody fusion techniques can be used to correct the lumbosacral kyphosis and restore the spinopelvic parameters. A complete reduction of the listhesis is not always required. The surgical procedure carried out in our patient corresponds to the first known case of minimally invasive circumferential arthrodesis with iliac screws and sacral fixation in a high-grade dysplastic spondylolisthesis. This approach guarantees the correction of the lumbosacral kyphosis and a complete reduction of the listhesis. Further studies are required to determine whether the results of this case can be extrapolated to other patients with high-grade spondylolisthesis.

Findings from a pilot randomized trial of spinal decompression alone or spinal decompression plus instrumented fusion

Aims

Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted.

Methods

As part of the SpInOuT-F study, a pilot randomized trial was carried out across five NHS hospitals. Patients were randomized to either spinal decompression alone or spinal decompression plus instrumented fusion. Patient-reported outcome measures were collected at baseline and three months. The intended sample size was 60 patients.

Results

Of the 90 patients screened, 77 passed the initial screening criteria. A total of 27 patients had a PI-LL mismatch and 23 had a dynamic spondylolisthesis. Following secondary inclusion and exclusion criteria, 31 patients were eligible for the study. Six patients were randomized and one underwent surgery during the study period. Given the low number of patients recruited and randomized, it was not possible to assess completion rates, quality of life, imaging, or health economic outcomes as intended.

Conclusion

This study provides a unique insight into the prevalence of dynamic spondylolisthesis and PI-LL mismatch in patients with symptomatic spinal stenosis, and demonstrates that there is a need for a definitive RCT which stratifies for these groups in order to inform surgical decision-making. Nonetheless a definitive study would need further refinement in design and implementation in order to be feasible.