Indication Variability in Degenerative Lumbar Spine Surgery: A Four-nation Survey

Surgeon variation: a south african spinal pathology treatment survey

PURPOSE

To investigate variation in treatment decisions among spine surgeons in South Africa and the association between surgeon characteristics and the treatment they select.

METHODS

We surveyed 79 South African spine surgeons. We presented four vignettes (cervical spine distractive flexion injury, lumbar disc herniation, degenerative spondylolisthesis with stenosis, and insufficiency fracture) for them to assess and select treatments. We calculated the index of qualitative variation (IQV) to determine the degree of variability within each vignette. We used Fisher's exact, and Kruskal-Wallis tests to assess the relationships between surgeons' characteristics and their responses per vignette. We compared their responses to the recommendations of a panel of spine specialists.

RESULTS

IQVs showed moderate to high variability for cervical spine distractive flexion injury and insufficiency fracture and slightly lower levels of variability for lumbar disc herniation and degenerative spondylolisthesis with stenosis. This confirms the heterogeneity in South African spine surgeons' management of spinal pathologies. The surgeon characteristics associated with their treatment selection that were important were caseload, experience and training, and external funding. Also, 19% of the surgeons selected a treatment option that the Panel did not support.

CONCLUSION

The findings make a case for evaluating patient outcomes and costs to identify value-based care. Such research would help countries that are seeking to contract with providers on value. Greater uniformity in treatment and easily accessible outcomes reporting would provide guidance for patients. Further investment in training and participation in fellowship programs may be necessary, along with greater dissemination of information from the literature.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons

BACKGROUND

Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis.

METHODS

The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree).

RESULTS

Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4).

CONCLUSIONS

Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Spine surgeons facing second opinions: a qualitative study

BACKGROUND CONTEXT

The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients.

PURPOSE

The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view.

STUDY DESIGN/SETTING

This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions.

PATIENT SAMPLE

We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared).

OUTCOME MEASURES

Themes and subthemes were analyzed using semistructured interviews until saturation was reached.

METHODS

Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon).

RESULTS

Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations).

CONCLUSIONS

The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach

PURPOSE

To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics.

METHODS

Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach.

RESULTS

Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit.

CONCLUSION

In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Application of single and cooperative different delivery systems for the treatment of intervertebral disc degeneration

Intervertebral disc (IVD) degeneration (IDD) is the most universal pathogenesis of low back pain (LBP), a prevalent and costly medical problem across the world. Persistent low back pain can seriously affect a patient's quality of life and even lead to disability. Furthermore, the corresponding medical expenses create a serious economic burden to both individuals and society. Intervertebral disc degeneration is commonly thought to be related to age, injury, obesity, genetic susceptibility, and other risk factors. Nonetheless, its specific pathological process has not been completely elucidated; the current mainstream view considers that this condition arises from the interaction of multiple mechanisms. With the development of medical concepts and technology, clinicians and scientists tend to intervene in the early or middle stages of intervertebral disc degeneration to avoid further aggravation. However, with the aid of modern delivery systems, it is now possible to intervene in the process of intervertebral disc at the cellular and molecular levels. This review aims to provide an overview of the main mechanisms associated with intervertebral disc degeneration and the delivery systems that can help us to improve the efficacy of intervertebral disc degeneration treatment.

Current treatment and decision-making factors leading to fusion vs decompression for one-level degenerative spondylolisthesis: survey results from members of the Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery

BACKGROUND

Degenerative spondylolisthesis (DS) is one of the most common pathologies spine surgeons treat. While a number of potential factors have been identified, there is no current consensus on which variables most impact the decision to fuse vs. decompress alone in this population.

PURPOSE

The purpose of this study was to describe current DS treatment practices and identify both the radiographic and clinical factors leading to the decision to fuse segments for one level DS.

STUDY DESIGN/SETTING

Descriptive cross-sectional survey.

PATIENT SAMPLE

Surveys were administered to members of Lumbar Spine Research Society and Society of Minimally Invasive Spine Surgery.

OUTCOME MEASURES

Surgeon demographics and treatment practices were reported. Radiographic and clinical parameters were ranked by each surgeon with regards to their importance.

METHODS

The primary analysis was limited to completed surveys. Baseline characteristics were summarized. Clinical and radiographic parameters were ranked and compared. Ranking of each clinical and radiographic parameters was reported using best and worst rank, mean rank position, and percentiles. The most important, top 3 most important, and top 5 most important parameters were ordered given each parameter's ranking frequency.

RESULTS

381 surveys were returned completed. With regards to fusion vs. decompression, 19.9% fuse all cases, 39.1% fuse > 75%, 17.8% fuse 50%-75%, and 23.2% fuse <25%. The most common decompressive technique was a partial laminotomy (51.4%), followed by full laminectomy (28.9%). 82.2% of respondents instrument all fusion cases. Instability (93.2%), spondylolisthesis grade (59.8%), and laterolisthesis (37.3%) were the most common radiographic factors impacting the decision to fuse. With regards to the clinical factors leading to fusion, mechanical low back pain (83.2%), activity level (58.3%), and neurogenic claudication (42.8%) were the top 3 clinical parameters.

CONCLUSIONS

There is little consensus on the treatment of DS, with society members showing substantial variation in treatment patterns with the majority utilizing fusion for treatment. The most common radiographic parameters impacting treatment are instability, spondylolisthesis grade, and laterolisthesis while mechanical low back pain, activity level, and neurogenic claudication are the most common clinical parameters.

Twelve-Month Results from a Prospective Clinical Study Evaluating the Efficacy and Safety of Cellular Bone Allograft in Subjects Undergoing Lumbar Spinal Fusion

BACKGROUND

While autologous bone grafts remain the gold standard for spinal fusion procedures, harvesting autologous bone is associated with significant complications, including donor site infection, hematomas, increased operative time, and prolonged pain. Cellular bone allograft (CBA) presents an alternative to autologous bone harvesting, with a favorable efficacy and safety profile. The current study further investigates CBA as an adjunct to lumbar spinal fusion procedures.

METHODS

A prospective, multicenter, open-label clinical study was conducted in subjects undergoing lumbar spinal fusion with CBA (NCT02969616). Radiographic fusion status was assessed by an independent review of dynamic radiographs and CT scans. Clinical outcome measures included the Oswestry Disability Index (ODI) and visual analogue scale (VAS) for back and leg pain. Adverse-event reporting was conducted throughout 12 months of follow-up. Available subject data at 12 months were analyzed.

RESULTS

A total of 274 subjects were enrolled into the study, with available data from 201 subjects (73.3%) who completed 12 months of postoperative radiographic and clinical evaluation at the time of analysis. Subjects had a mean age of 60.2 ± 11.5 years. A higher number of women (n = 124, 61.7%) than men (n = 77, 38.3%) were enrolled, with a collective mean BMI of 30.6 + 6.5 kg/m² (range 18.0-51.4). At month 12, successful fusion was achieved in 90.5% of subjects. A significant (<i>p</i> &amp;lt; 0.001) improvement in ODI, VAS-back, and VAS-leg clinical outcomes was also observed compared to baseline scores. One adverse event related to CBA (postoperative radiculopathy) was reported, with surgical exploration demonstrating interbody extrusion of graft material. This subject reported successful fusion at month 12.

CONCLUSIONS

CBA represents a viable substitute for harvesting of autograft alone with a high rate of successful fusion and significant improvements in subject-reported outcomes, such as pain and disability. Positive benefit was observed in subjects reporting single and multiple risk factors for pseudoarthrosis.

The Relation of Surgical Procedures and Diagnosis Groups to Unplanned Readmission in Spinal Neurosurgery: A Retrospective Single Center Study

Background: Unplanned readmission has gained increasing interest as a quality marker for inpatient care, as it is associated with patient mortality and higher economic costs. Spinal neurosurgery is characterized by a lack of epidemiologic readmission data. The aim of this study was to identify causes and predictors for unplanned readmissions related to index diagnoses and surgical procedures. Methods: In this study, from 2015 to 2017, spinal neurosurgical procedures were recorded for surgical and non-surgical treated patients. The main reasons for an unplanned readmission within 30 days following discharge were identified. Multivariate logarithmic regression revealed predictors of unplanned readmission. Results: A total of 1172 patient records were examined, of which 4.27% disclosed unplanned readmissions. Among the surgical patients, the readmission rate was 4.06%, mainly attributable to surgical site infections, while it was 5.06% for the non-surgical patients, attributable to uncontrolled pain. A night-time surgery presented as the independent predictive factor. Conclusion: In the heterogeneous group of spinal neurosurgical patients, stratification into diagnostic groups is necessary for statistical analysis. Degenerative lumbar spinal stenosis and spinal abscesses are mainly affected by unplanned readmission. The surgical procedure dorsal root ganglion stimulation is an independent predictor of unplanned re-hospitalizations, as is the timing of surgery.

Intervertebral Disc Degeneration: Biomaterials and Tissue Engineering Strategies toward Precision Medicine

Intervertebral disc degeneration is a common cause of discogenic low back pain resulting in significant disability. Current conservative or surgical intervention treatments do not reverse the underlying disc degeneration or regenerate the disc. Biomaterial-based tissue engineering strategies exhibit the potential to regenerate the disc due to their capacity to modulate local tissue responses, maintain the disc phenotype, attain biochemical homeostasis, promote anatomical tissue repair, and provide functional mechanical support. Despite preliminary positive results in preclinical models, these approaches have limited success in clinical trials as they fail to address discogenic pain. This review gives insights into the understanding of intervertebral disc pathology, the emerging concept of precision medicine, and the rationale of personalized biomaterial-based tissue engineering tailored to the severity of the disease targeting early, mild, or severe degeneration, thereby enhancing the efficacy of the treatment for disc regeneration and ultimately to alleviate discogenic pain. Further research is required to assess the relationship between disc degeneration and lower back pain for developing future clinically relevant therapeutic interventions targeted towards the subgroup of degenerative disc disease patients.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Variability in Management Practices and Surgical Decision Making in Spinal Tuberculosis: An Expert Survey-Based Study

Study Design

Electronic survey–based study.

Purpose

The aim of the study was to objectively review the variability in the prevailing treatment protocols and surgical decision making in the management of patients with spinal tuberculosis (TB) among spine surgeons with expertise in spinal TB across the country.

Overview of Literature

A lack of good-quality evidence, ambiguities in the national spinal TB guidelines, and the demand for early rehabilitation and a better quality of life in patients with spinal TB has led to the emergence of various gray zones in the management of spinal TB.

Methods

Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents.

Results

High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO.

Conclusions

Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.

Impact of surgeon and hospital factors on surgical decision-making for grade 1 degenerative lumbar spondylolisthesis: a Quality Outcomes Database analysis

OBJECTIVE

Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD).

METHODS

The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0-10, 11-20, 21-30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection.

RESULTS

A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09-4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59-2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19-0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors.

CONCLUSIONS

Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

The Current Practice of Adult Idiopathic Scoliosis Surgical Treatment Among Spine Surgeons in Saudi Arabia

Background: Scoliosis is a spinal deformity consisting of lateral curvature and rotation of the vertebrae. The goal of corrective scoliosis surgery is to restore alignment of the spine and maintain motion. However, there is no global agreement among spine surgeons on the best method of surgical intervention, and little is known about the variations in practice among spine surgeons in Saudi Arabia.

Objectives: The aim of this study is to examine the current surgical practices relating to adolescent idiopathic scoliosis and to establish the degree of variation and consensus among spine surgeons in Saudi Arabia.

Methods: This was a cross-sectional study conducted among spine surgeons in Saudi Arabia, using a self-administered questionnaire. The questionnaire addressed four areas: surgeons’ demographics, pre-operative assessment, operative assessment, and infection control practices. There were a total of 27 questions. Data was analyzed using statistical package for social sciences (SPSS) software (SPSS Inc., Chicago, IL, USA).

Results: A total of 150 surgeons were included in this study. Of these, 73 responded to the questionnaire (response rate: 48.6%), 46 (63.01%) of whom were fellows. All respondents were males, and 37 (51.39%) were aged between 30 and 40 years. Fifty five (75.34%) were orthopedic surgeons. The most commonly used pre-operative health assessment test was an echocardiogram. Sixty six (90%) surgeons requested scoliosis anteroposterior (AP) view and lateral radiograph for curvature between 40 degrees and 90 degrees, and 65 (89%) requested it for curvature greater than 90 degrees. For the posterior construct, 29 (45.31%) did not use cross-links for fewer than 10 levels, and 23 (35.94%) did not use cross-links for more than 10 levels. In addition to a local bone graft, the most commonly used transplant method was allograft 37 (50.68%). Fifty five (85.94%) respondents favored an all-screw pedicle construct over a hybrid construct.

Conclusion: A large variation in surgical practices was observed. This was especially apparent in practices including the use of cross-links, intra-operative cell salvage, and the intra-operative use of traction. Some degree of variation was observed in pre-operative imaging assessment practices. Surgical guidelines should be developed to build a consensus among surgeons. A unified surgical training curriculum may help in achieving this goal.

Current incidence of adjacent segment pathology following lumbar fusion versus motion-preserving procedures: a systematic review and meta-analysis of recent projections

BACKGROUND CONTEXT

Lumbar fusion has shown to be an effective surgical management option when indicated, improving patient outcomes and functional status. However, concerns of adjacent segment pathology (ASP) due to reduced mobility at the operated segment have fostered the emergence of motion-preserving procedures (MPP).

PURPOSE

To assess rates of radiographic adjacent segment degeneration (ASDeg) and symptomatic adjacent segment disease (ASDis) as well as reoperation rates due to ASP in patients who have undergone lumbar fusion compared to motion-preservation for degenerative disorders.

STUDY DESIGN

Systematic Review and Meta-Analysis.

METHODS

Following PRISMA guidelines, a systematic review and meta-analysis was conducted to find current (1/2012-12/2019) retrospective cohort studies and randomized controlled trials evaluating rates of ASDeg, ASDis, and reoperations due to lumbar ASP.

RESULTS

A total of 1,751 patients (791 underwent fusion surgery and 960 motion-preserving procedures) in 19 publications were included in the final analysis. Overall incidence rates of ASDeg, ASDis, and reoperation rates were 27.8%, 7.6%, and 4.6%, respectively. Results showed no significant difference between the lumbar fusion versus MPP cohorts in incidence of ASDeg (36.4% vs. 19.2%, p: 0.06), ASDis (10.7% vs. 4.42%, p: 0.25), or reoperation due to ASP (7.40% vs. 1.80%, p: 0.19). Fixed-effects analysis revealed patients who underwent MPP had significantly lower odds of ASDeg (OR: 2.57, CI: 1.95, 3.35, p<.05) and reoperations (OR: 3.18, CI: 1.63, 6.21, p<.05) compared to lumbar fusion patients.

CONCLUSIONS

This meta-analysis revealed no statistically significant difference in incidence of ASDeg, ASDis, or reoperations due to ASP for patients after lumbar fusion versus MPP. Weighted analysis, however, showed that MPP patients had significantly lower odds of ASDeg and reoperations due to ASP. While previous studies have established the biomechanical efficacy of MPP on cadaveric models, further high-quality studies are required to evaluate the long-term consequences of these procedures on patient-reported outcomes, postoperative complications, and associated inpatient/outpatient costs.

Knee or Spine Surgery First? A Survey of Treatment Order for Patients With Concurrent Degenerative Knee and Lumbar Spinal Disorders

BACKGROUND

Total knee arthroplasty (TKA) and lumbar spine surgery have been reported to affect the outcomes of each other. There is insufficient evidence to guide the choice of treatment order for patients with both disorders that are equally symptomatic.

METHODS

Five clinical scenarios of concurrent, advanced, degenerative knee and lumbar spinal disorders were designed to survey surgeons' choices of treatment order and rationale. The spinal disorder was consistently degenerative lumbar spinal stenosis, but the knee conditions varied to include (1) osteoarthritis (OA) with varus deformity, (2) OA with valgus deformity, (3) rheumatoid arthritis with a severe flexion contracture, (4) OA without deformity, and (5) bilateral OA with windswept deformities. The survey was distributed to selected clinical members of the Knee Society and Scoliosis Research Society in North America. The surgeons' choices were compared among the 5 scenarios, and their comments were analyzed using text-mining.

RESULTS

Responses were received from 42 of 74 (57%) knee arthroplasty surgeons and 55 of 100 (55%) spine surgeons. The percentages of knee arthroplasty surgeons recommending "TKA first" differed significantly among scenarios: 29%, 79%, 55%, 7%, and 81% for scenarios 1 through 5, respectively (P < .001). A similar pattern was noted for the spine surgeons.

CONCLUSION

For patients with concurrent degenerative knee and lumbar spinal disorders, the severity and type of knee deformity influenced the preference of treatment order in both specialties. Severe valgus deformity and windswept deformities of the knee would drive the decision toward "TKA first."

Second Opinions before Surgery Have the Potential to Reduce Costs - An Exploratory Analysis

AIM

In this study cost data of patient's first and second opinion of a German second opinion program of patients with orthopedic indications are raised and compared.

METHODS

Anonymized patient data were used from a second opinion program gathered in the period from 2013 to 2015. Costs of the first and second opinion were raised using DRG, the EBM catalog, the remuneration agreement on physical therapy and the price of drugs. In order to increase transferability, initial therapy recommendation and second opinion were compared in a cost analysis to determine a theoretical savings potential.

RESULTS

A total of 170 consecutive patients with orthopedic indication and first and second opinion were analyzed in this study. Only one out of three initial therapy recommendations was confirmed by the second opinion. In the second opinion, physiotherapy and pain therapy were often suggested for indications which received a surgery referral by the initial therapy recommendation. In scenario 1 (average resource use), the costs of the first therapy recommendation in median was 5020.96 € (IQR = 961.71 - 7342.66), the second opinion was 322.07 € (IQR = 146.39 - 1341.32). In median, the operation costs of the initial therapy recommendation were equal to 156.12 physiotherapeutic sessions and 26.02 N3 packs Ibuprofen 800.

CONCLUSION

Therapy costs for the initial therapy recommendation are clearly exceeding the therapy costs of the second opinion. This assumes a potential to reduce therapy costs with the use of a second opinion. This study lays the foundation to carry out further conclusive analyses concerning this matter.

Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial

BACKGROUND

Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level.

METHOD

In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed.

RESULTS

Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association.

CONCLUSION

Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery.

TRIAL REGISTRATION

NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.

Hip or spine surgery first?: a survey of treatment order for patients with concurrent degenerative hip and spinal disorders

AIMS

Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain.

MATERIALS AND METHODS

Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining.

RESULTS

Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending 'hip first' differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending 'hip first' were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended 'hip first'; p = 0.012) and 4 (more hip surgeons recommended 'spine first'; p = 0.006).

CONCLUSION

In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of 'hip or spinal surgery first' elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons' decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37-44.

Elective lumbar fusion in the United States: national trends in inpatient complications and cost from 2002-2014

BACKGROUND

Elective fusions for degenerative spine disease have increased over the past two decades in the United States, with variability in complications and hospital costs. The additional service costs associated with adverse perioperative events remain unknown. Our objective is to improve understanding of trends in safety and cost of elective lumbar fusions on a national scale.

METHODS

A weighted sample of 1,526,386 adults undergoing elective lumbar fusion for degenerative indications were identified in the National Inpatient Sample (NIS) years 2002-2014. Twelve categories of major complications by system, and patient/hospital variables, were evaluated as predictors of the overall reimbursed cost. Mean differences (B) and 95% confidence intervals [95% CI] are reported. Significance is assessed at p<0.001.

RESULTS

Nineteen percent of patients experienced inpatient complication. After adjusting for inflation, the mean overall cost was $32802±19557. Costs increased with presence of each of the 12 categories of complications, and by number of levels fused. Rates of most frequent complications and their adjusted cost-of-care were acute postoperative anemia (11.2%, B=$1817 [$1722-$1913], p<0.001), renal/urinary (1.9%, B=$510 [$288-$732], p<0.001), pulmonary (1.8%, B=$6014 [$5785-6243], p<0.001) and gastrointestinal (1.8%, B=$3699 [$3490-$3908, p<0.001). The costliest adverse events were infection (B=$15882 [$15424-$16339], p<0.001), thromboembolism (B=$8856 [$8400-$9311], p<0.001), hematoma/seroma/vascular (B=$8050 [$7784-$8316], p<0.001).

CONCLUSIONS

The number of elective lumbar fusions for degenerative spine disease increased 276% in the United States from 2002-2014 with growing surgeon preference for lateral techniques, and an increasing proportion of combined anterior and posterior approaches. Overall complication rates decreased from 2002-2014, despite an older patient population. After adjusting for inflation, cost was relatively stable across years 2002-2014. Complications by system were associated with increased cost, underscoring the need to address sources of complications and optimize early postoperative recovery in order to reduce healthcare expenditure.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.