Patient-Based Surgical Outcomes of Posterior Lumbar Interbody Fusion: Patient Satisfaction Analysis

Effect of segmental lordosis on early-onset adjacent-segment disease after posterior lumbar interbody fusion

OBJECTIVE

Although several reports have described adjacent-segment disease (ASD) after posterior lumbar interbody fusion (PLIF), there have been only a few reports focusing on early-onset ASD occurring within 3 years after primary PLIF. The purpose of this study was to investigate the prevalence and postoperative pathologies of early-onset ASD and its relation with radiological parameters such as segmental lordosis (SL).

METHODS

The authors reviewed a total of 256 patients who underwent single-segment PLIF at L4-5 for degenerative lumbar spondylolisthesis (DLS) and were followed up for at least 5 years. The definition of ASD was a symptomatic condition requiring an additional operation at the adjacent fusion segment in patients who had undergone PLIF. ASD occurring within 3 years after primary PLIF was categorized as early-onset ASD. As a control group, 54 age- and sex-matched patients who had not suffered from ASD for more than 10 years were selected from this series.

RESULTS

There were 42 patients with ASD at the final follow-up. ASD prevalence rates at 3, 5, and 10 years postoperatively and at the final follow-up were 5.0%, 8.2%, 14.1%, and 16.4%, respectively. With respect to ASD pathologies, lumbar disc herniation (LDH) was significantly more common in early-onset ASD, while lumbar spinal stenosis and DLS occurred more frequently in late-onset ASD. Significant differences were detected in the overall postoperative range of motion (ROM) and in the changes in ROM (ΔROM) at L3-4 (the cranial adjacent fusion segment) and changes in SL (ΔSL) at L4-5 (the fused segment), while there were no significant differences in other pre- and postoperative parameters. In stepwise logistic regression analysis, ΔSL was identified as an independent variable (p = 0.008) that demonstrated significant differences, especially in early-onset ASD (control 1.1° vs overall ASD -2.4°, p = 0.002; control 1.1° vs early-onset ASD -6.6°, p = 0.00004).

CONCLUSIONS

The study results indicated that LDH was significantly more common as a pathology in early-onset ASD and that ΔSL was a major risk factor for ASD, especially early-onset ASD.

Comparing Investigation Between Bilateral Partial Laminectomy and Posterior Lumbar Interbody Fusion for Mild Degenerative Spondylolisthesis

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

The present study aims to compare the surgical outcomes between bilateral partial laminectomy (BPL) and posterior lumbar interbody fusion (PLIF) in patients with mild degree of slippage.

SUMMARY OF BACKGROUND DATA

To date, there have not been established surgical procedures for patients with mild degree of slippage. Moreover, sufficient studies that have compared surgical outcomes between BPL and PLIF are very few.

MATERIALS AND METHODS

In this retrospective study, the authors enrolled 202 consecutive patients with degenerative spondylolisthesis with slippage at L3 or L4 of >3% who underwent spine surgery between 2005 and 2015. Patients were grouped into those who underwent single-segment PLIF (n=106) and those who underwent BPL (n=51). To adjust for potential confounders, the inverse probability of treatment weighting based on the propensity score was used. Surgical outcomes were compared between the BPL and PLIF groups. The threshold age for the final recovery rate of >70% was evaluated using receiver operating characteristic curve analyses to assess the limit of age to achieve good outcomes. Patients who underwent reoperation in both groups were also evaluated.

RESULTS

Operation time and blood loss were significantly lower in the BPL group. The final recovery rate was similar between the groups without age stratification. The cutoff age to achieve a final recovery rate of >70% was 75 years in the PLIF group, and the final recovery rate was significantly higher in the PLIF group than in the BPL group in patients aged less than 75 years but not in patients aged 75 years or older. In addition, the reoperation rate was similar between groups, and all reoperations in the PLIF group were for adjacent segment disease.

CONCLUSIONS

BPL is one of the useful options in patients with mild degenerative spondylolisthesis, particularly in patients aged more than 75 years.

Two-level Posterior Lumbar Interbody Fusion at the Lumbosacral Segment has a High Risk of Pseudarthrosis and Poor Clinical Outcomes: Comparison Between the Lumbar and Lumbosacral Segments

STUDY DESIGN

This was a retrospective study.

OBJECTIVES

The purposes of this study were to investigate the fusion rate and clinical outcomes of 2-level posterior lumbar interbody fusion (PLIF).

SUMMARY OF BACKGROUND DATA

PLIF provides favorable clinical outcomes and a high fusion rate. However, most extant studies have been limited to the results of single-level PLIF. Clinical outcomes and fusion rate of 2-level PLIF are unknown.

MATERIALS AND METHODS

In total, 73 patients who underwent 2-level PLIF below L3 between 2008 and 2016 (follow-up period >2 y) were included. Patients were divided into the 2 groups on the basis of surgical level. The lumbar group included 48 patients who underwent L3/4/5 PLIF, and the lumbosacral group included 25 patients who underwent L4/5/S PLIF. Fusion rate and clinical outcomes were compared. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and a visual analog scale were used for evaluation.

RESULTS

Fusion rate was significantly lower in the lumbosacral group (lumbar 96% vs. lumbosacral 64%; P<0.001). Eight of 9 cases of pseudarthrosis occurred at the lumbosacral segment. Improvement in the mental health domain of the JOAPEQ was significantly lower in the lumbosacral group (lumbar 16 vs. lumbosacral 10; P=0.02). The VAS data showed that improvements in the following variables were significantly lower in the lumbosacral group than in the lumbar group: pain in low back (lumbar -38 vs. lumbosacral -23; P=0.004), pain in buttocks or lower leg (lumbar -48 vs. lumbosacral -29; P=0.04), and numbness in buttocks or lower leg (lumbar -44 vs. lumbosacral -33; P=0.04).

CONCLUSIONS

Two-level PLIF at the lumbosacral segment demonstrated a significantly lower fusion rate and poorer clinical outcomes than that at the lumbar-only segments. Some reinforcement for the sacral anchor is recommended to improve fusion rate, even for short fusion like 2-level PLIF, if the lumbosacral segment is included.

LEVEL OF EVIDENCE

Level III.

[Comparative study on effectiveness of modified-transforaminal lumbar interbody fusion and posterior lumbar interbody fusion surgery in treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients]

OBJECTIVE

To compare the effectiveness of modified transforaminal lumbar interbody fusion (modified-TLIF) and posterior lumbar interbody fusion (PLIF) for mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients.

METHODS

The clinical data of 106 patients with mild to moderate lumbar spondylolisthesis (Meyerding classification≤Ⅱ degree) who met the selection criteria between January 2015 and January 2017 were retrospectively analysed. All patients were divided into modified-TLIF group (54 cases) and PLIF group (52 cases) according to the different surgical methods. There was no significant difference in preoperative clinical data of gender, age, disease duration, sliding vertebra, Meyerding grade, and slippage type between the two groups ( P>0.05). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, hospital stay, and complications of the two groups were recorded and compared. The improvement of pain and function were evaluated by the visual analogue scale (VAS) score and Japanese Orthopedic Association (JOA) score at preoperation, 1 week, and 1, 6, 12 months after operation, and last follow-up, respectively. The effect of slip correction was evaluated by slip angle and intervertebral altitude at preoperation and last follow-up, and the effectiveness of fusion was evaluated according to Suk criteria.

RESULTS

All patients were followed up, the modified-TLIF group was followed up 25-36 months (mean, 32.7 months), the PLIF group was followed up 24-38 months (mean, 33.3 months). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, and hospital stay of the modified-TLIF group were significantly less than those of the PLIF group ( P<0.05). The VAS score and JOA score of both groups were significantly improved at each time point after operation ( P<0.05); the scores of the modified-TLIF group were significantly better than those of the PLIF group at 1 and 6 months after operation ( P<0.05). The slip angle and intervertebral altitude of both groups were obviously improved at last follow-up ( P<0.05), and there was no significant difference between the two groups at preoperation and last follow-up ( P>0.05). At last follow-up, the fusion rate of the modified-TLIF group and the PLIF group was 96.3% (52/54) and 98.1% (51/52), respectively, and no significant difference was found between the two groups ( χ 2=0.000, P=1.000). About complications, there was no significant difference between the two groups in nerve injury on the opposite side within a week, incision infection, and pulmonary infection ( P>0.05). No case of nerve injury on the operation side within a week or dural laceration occurred in the modified-TLIF group, while 8 cases (15.4%, P=0.002) and 4 cases (7.7%, P=0.054) occurred in the PLIF group respectively.

CONCLUSION

Modified-TLIF and PLIF are effective in the treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients. However, modified-TLIF has relatively less trauma, lower blood loss, lower drainage volume, lower incidence of dural laceration and nerve injury, which promotes enhanced recovery after surgery.

Effect of segmental lordosis on the clinical outcomes of 2-level posterior lumbar interbody fusion for 2-level degenerative lumbar spondylolisthesis

OBJECTIVE

Although the importance of spinopelvic sagittal balance and its implications for clinical outcomes of spinal fusion surgery have been described, to the authors' knowledge there have been no reports of the relationship between spinopelvic alignment and clinical outcomes for 2-level posterior lumbar interbody fusion (PLIF). The purpose of this study was to elucidate the relationship between clinical outcomes and spinopelvic sagittal parameters after 2-level PLIF for 2-level degenerative spondylolisthesis (DS).

METHODS

This study was limited to patients who were treated with 2-level PLIF for 2-level DS at L3-4-5. Between 2005 and 2014, 33 patients who could be followed up for at least 2 years were included in this study. The average age at the time of surgery was 72 years, and the average follow-up period was 5.6 years. Based on clinical assessments, the Japanese Orthopaedic Association (JOA) score and recovery rate were evaluated. The patients were divided into 2 groups based on the recovery rate: the good outcome group (G group; n = 19), with recovery rate ≥ 50%, and the poor outcome group (P group; n = 14) with recovery rate < 50%. Spinopelvic parameters were measured using lateral standing radiographs of the whole spine as follows: sagittal vertical axis (SVA), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis (SL) at L3-4-5. The clinical outcomes and radiological parameters were assessed preoperatively and at the final follow-up. Radiological parameters were compared between the 2 groups.

RESULTS

The mean JOA score improved significantly in all patients from 10.8 points before surgery to 19.6 points at the latest follow-up (mean recovery rate 47.7%). For radiological outcomes, no difference was observed from preoperative assessment to final follow-up in any of the spinopelvic parameters except SVA. Although no significant difference between the 2 groups was detected in any of the spinopelvic parameters, there were significant differences in the change in SL and LL (ΔSL 3.7° vs -2.1° and ΔLL 1.2° vs -5.6° for the G and P groups, respectively). In addition, the number of patients in the G group was significantly larger for the patients with ΔSL-plus than those with ΔSL-minus (p = 0.008).

CONCLUSIONS

The clinical outcomes of 2-level PLIF for 2-level DS limited at L3-4-5 appeared to be satisfactory. The results indicate that acquisition of increased SL in surgery might lead to better clinical outcomes.

Effects of Concomitant Decompression Adjacent to a Posterior Lumbar Interbody Fusion Segment on Clinical and Radiologic Outcomes: Comparative Analysis 5 Years After Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To examine the effects of concomitant decompression adjacent to the posterior lumbar interbody fusion (PLIF) segment on the clinical and radiological outcomes 5 years after surgery.

METHODS

Forty-five consecutive patients who had undergone L3/4 decompression with L4/5 PLIF for multilevel stenosis with degenerative spondylolisthesis (DS), and were followed for 5 years, were enrolled (group D). As a control group, 45 age-, sex- and preoperative disc height at L3/4-matched patients who had undergone L4/5 PLIF alone for L4/5DS were randomly selected (group A). Disc height, vertebral slippage, range of motion, posterior opening angle, segmental lordotic angle, presence of the intradiscal vacuum phenomenon (IVP) at the L3/4 level were measured on radiographs. Japanese Orthopaedic Association (JOA) score and the requirement for additional L3/4 surgery were evaluated.

RESULTS

In terms of pre-/postoperative radiographic changes between the groups, significant differences were detected regarding disc height narrowing of ≥3 mm (group D 31%, group A 9%) and IVP (group D 33%, group A 11%). There were no significant differences in other radiological parameters. The recovery rate of the JOA score (group D 58%, group A 61%) and reoperation rate (group D 2.2%, group A 6.7%) were not significantly different between the groups.

CONCLUSION

Concomitant decompression adjacent to the PLIF segment accelerated adjacent disc degeneration compared to PLIF alone, but it did not predispose to the development of instability 5 years after surgery. Moreover, the JOA score and reoperation rate were not significantly different between groups D and A.

Adjacent Segment Disease After Single Segment Posterior Lumbar Interbody Fusion for Degenerative Spondylolisthesis: Minimum 10 Years Follow-up

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to investigate the incidence of adjacent segment disease (ASD) at 2, 5, and 10 years after primary posterior lumbar interbody fusion (PLIF), and clinical features of ASD.

SUMMARY OF BACKGROUND DATA

Few reports have examined ASD after PLIF with more than 10 years of follow-up. Furthermore, no reports have examined limited conditions of preoperative pathology, fusion segment, and fusion method with long follow-up.

METHODS

Data were reviewed for 128 patients who underwent single-segment PLIF for L4 degenerative spondylolisthesis and could be followed for at least 10 years. Mean age at the time of surgery was 63 years, and mean follow-up was 12.4 years. Follow-up rate was 62.4%. ASD was defined as radiological ASD (R-ASD), radiological degeneration adjacent to the fusion segment by plain X-rays and magnetic resonance imaging (MRI); symptomatic ASD (S-ASD), a symptomatic condition due to neurological deterioration at the adjacent segment degeneration; and operative ASD (O-ASD), S-ASD requiring revision surgery.

RESULTS

Incidences of each ASD at 2, 5, and 10 years after primary PLIF were 19%, 49%, and 75% for R-ASD, 6%, 14%, and 31% for S-ASD, and 5%, 9%, and 15% for O-ASD, respectively. O-ASD incidence was 24% at final follow-up. O-ASD peak was bimodal, at 2 and 10 years after primary PLIF. O-ASD was mainly observed at the cranial segment (77%), followed by the caudal segment (13%) and both cranial and caudal segments (10%). With respect to O-ASD pathology, degenerative spondylolisthesis was observed in 52%, spinal stenosis in 39%, and disc herniation in 10%.

CONCLUSION

Incidences of R-ASD, S-ASD, and O-ASD at 10 years after primary PLIF were 75%, 31%, and 15%, respectively. With respect to O-ASD pathology, degenerative spondylolisthesis at the cranial segment was the most frequent.

LEVEL OF EVIDENCE

4.

Controllable Risk Factors for Neurologic Complications in Posterior Lumbar Interbody Fusion as Revision Surgery

BACKGROUND

The main concern with revision lumbar surgery is the possibility of neurologic complications. This retrospective study was conducted to clarify the risk factors, especially the effects of nerve stretching, for postoperative neurologic complications in posterior lumbar interbody fusion (PLIF) without excessive nerve retraction by bilateral total facetectomy as revision surgery.

METHODS

Between 2005 and 2015, 50 consecutive patients underwent revision PLIF for recurrent stenosis or recurrent disc herniation. The patients were divided into two groups: patients with neurological complications (NC group) and patients without neurological complications (non-NC group). Radiological examinations to evaluate the magnitude of nerve stretching included the following pre- and postoperative plain radiograph measurements: anterolisthesis at flexion, intervertebral lordosis in the neutral position, and posterior disc height in the neutral position.

RESULTS

Sixteen patients (32%) had neurological complications. The decrease in intervertebral lordosis was significantly greater in the NC group than that in the non-NC group (0.8° vs. -1.5°, P<0.05). Distraction of the posterior disc height was significantly greater in the NC group than that in the non-NC group (5.0 mm vs. 2.6 mm, P < 0.01). Neurological complications were seen in all patients with a decrease in intervertebral lordosis >3° and distraction of the posterior disc height >3 mm.

CONCLUSIONS

Decreased intervertebral lordosis, and distraction of the posterior disc height, which can be controlled by surgeons, appear to be risk factors for neurological complications following revision PLIF. In revision PLIF, surgeons should create segmental lordosis without excessive disc height distraction.

Factors associated with patient satisfaction for PLIF: Patient satisfaction analysis

Introduction: Posterior lumbar interbody fusion (PLIF) has produced satisfactory clinical outcomes; however, all previous reports have only included evaluations by surgeon-based methods. The purpose of this study was to investigate patient-based surgical outcomes and the factors associated with patient satisfaction for PLIF. Methods: Patients who underwent PLIF for lumbar spondylolisthesis were reviewed (n=443). The average follow-up period was 8 years. Surgical outcomes were assessed using an original questionnaire, a numerical rating scale (NRS), the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association (JOA) score, and the recovery rate. The original questionnaire consisted of five categories, with patient-evaluated score out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery on a 5-point scale. According to the questionnaire responses, patient-based outcomes were divided into three groups: positive, intermediate, and negative and were compared with the NRS, SF-36, and JOA scores. Furthermore, factors associated with patient satisfaction were examined. Results: A total of 273 patients responded. Response rate was 62%. The average patient-evaluated score for surgery was 82 points. In terms of satisfaction section, positive, intermediate, and negative response rates were 82%, 7%, and 11%, respectively. With respect to other sections, positive, intermediate, and negative response rates were 87%, 7%, and 6% in improvement section; 66%, 23%, and 11% in recommending section; and 72%, 18%, and 10% in repeat section, respectively. The average pre- and postoperative JOA scores were 12 and 24, respectively. Significant correlations were detected between patient-based surgical outcomes and the NRS scores, physical component scores of the SF-36, and the JOA score. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response. Conclusions: High satisfaction rate to PLIF and significant correlation between patient- and surgeon-based surgical outcomes were detected. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response.

Provider-Initiated Patient Satisfaction Reporting Yields Improved Physician Ratings Relative to Online Rating Websites

Recently, providers have begun to publicly report the results of patient satisfaction surveys from their practices. However, these outcomes have never been compared with the findings of commercial online physician rating websites. The goals of the current study were to (1) compare overall patient satisfaction ratings for orthopedic surgeons derived from provider-based third-party surveys with existing commercial physician rating websites and (2) determine the association between patient ratings and provider characteristics. The authors identified 12 institutions that provided publicly available patient satisfaction outcomes derived from third-party surveys for their orthopedic surgeons as of August 2016. Orthopedic surgeons at these institutions were eligible for inclusion (N=340 surgeons). Provider characteristics were recorded from publicly available data. Four high-traffic commercial online physician rating websites were identified: Healthgrades.com, UCompareHealthCare.com, Vitals.com, and RateMDs.com. For each surgeon, overall ratings (on a scale of 1-5), total number of ratings, and percentage of negative ratings were compared between provider-initiated internal ratings and each commercial online website. Associations between baseline factors and overall physician ratings and negative ratings were assessed. Provider-initiated internal patient satisfaction ratings showed a greater number of overall patient ratings, higher overall patient satisfaction ratings, and a lower percentage of negative comments compared with commercial online physician rating websites. A greater number of years in practice had a weak association with lower internal ratings, and an academic practice setting and a location in the Northeast were protective factors for negative physician ratings. Compared with commercial online physician rating websites, provider-initiated patient satisfaction ratings of orthopedic surgeons appear to be more favorable, with greater numbers of responses. [Orthopedics. 2017; 40(5):304-310.].