Nationwide trends in the surgical management of lumbar spinal stenosis

Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Methods

The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded.

Results

Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)).

Conclusion

Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis.

American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator as a Predictor of Postoperative Outcomes After Adult Spinal Deformity Surgery: A Retrospective Cohort Analysis

BACKGROUND AND OBJECTIVES

In recent years, there has been an outpouring of scoring systems that were built to predict outcomes after various surgical procedures; however, research validating these studies in spinal surgery is quite limited. In this study, we evaluated the predictability of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) for various postoperative outcomes after spinal deformity surgery.

METHODS

A retrospective chart review was conducted to identify patients who underwent spinal deformity surgery at our hospital between January 1, 2014, and December 31, 2022. Demographic and clinical data necessary to use the ACS NSQIP SRC and postoperative outcomes were collected for these patients. Predictability was analyzed using the area under the curve (AUC) of receiver operating characteristic curves and Brier scores.

RESULTS

Among the 159 study patients, the mean age was 64.5 ± 9.5 years, mean body mass index was 31.9 ± 6.6, and 95 (59.7%) patients were women. The outcome most accurately predicted by the ACS NSQIP SRC was postoperative pneumonia (observed = 5.0% vs predicted = 3.2%, AUC = 0.75, Brier score = 0.05), but its predictability still fell below the acceptable threshold. Other outcomes that were underpredicted by the ACS NSQIP SRC were readmission within 30 days (observed = 13.8% vs predicted = 9.0%, AUC = 0.63, Brier score = 0.12), rate of discharge to nursing home or rehabilitation facilities (observed = 56.0% vs predicted = 46.6%, AUC = 0.59, Brier = 0.26), reoperation (observed 11.9% vs predicted 5.4%, AUC = 0.60, Brier = 0.11), surgical site infection (observed 9.4% vs predicted 3.5%, AUC = 0.61, Brier = 0.05), and any complication (observed 33.3% vs 19%, AUC = 0.65, Brier = 0.23). Predicted and observed length of stay were not significantly associated (β = 0.132, P = .47).

CONCLUSION

The ACS NSQIP SRC is a poor predictor of outcomes after spinal deformity surgery.

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.

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.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Comparing the Efficacy of Transforaminal and Caudal Epidural Injections of Calcitonin in Treating Degenerative Spinal Canal Stenosis: A Double-Blind Randomized Clinical Trial

Background

Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS.

Objectives

This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS.

Methods

In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed.

Results

The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05).

Conclusions

The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.

Trends in lumbar interbody fusion: A study of American Board of Orthopedic Surgery (ABOS) candidate data

Background

There has been an increase in posterior-based interbody fusions over the past two decades. Our objective was to evaluate trends in interbody fusion use among the American Board of Orthopedic Surgery (ABOS) Part II candidates.

Methods

The ABOS database from 2003 to 2012 was queried for common procedural terminology (CPT) codes indicating lumbar interbody fusion (22,558 anterior lumbar interbody fusion [ALIF] and 22,630 and 22,633 posterior lumbar interbody fusion [PLIF] or transforaminal lumbar interbody fusion [TLIF]). Trends in the use of interbody fusion technique, associated complications, and geographical variation were evaluated. We also queried utilization of the anterior and posterior interbody fusions by the International Classification of Diseases-9 code.

Results

6841 interbody fusion cases were identified (2329 ALIF and 4512 PLIF/TLIF). There was a significantly higher use of PLIF/TLIF than ALIF over the study period (P < 0.001). As compared to patients in the Midwest, those in the Northwest had significantly higher odds of undergoing PLIF/TLIF (odds ratio [OR]: 4.79, 95% confidence interval [CI]: 3.61-6.35, P <0.001), and those in the Southwest had significantly lower odds of PLIF/TLIF (OR: 0.81, 95% CI: 0.69-0.95, P = 0.01). The overall complication rate was 22.2% (n = 1,519). Vascular-related complications were significantly higher among patients undergoing ALIF (31 vs. 1, P <0.001), while those undergoing TLIF/PLIF were more likely to experience unspecified medical complications. On multivariate analysis, patients undergoing PLIF/TLIF had lower odds of experiencing a complication (P = 0.03, OR 0.87, CI 95%).

Conclusion

Over the 10-year study period, there has been a significantly increased rate of posterior interbody fusion among candidates taking part II ABOS examination.

Are Clinical or Surgical Outcomes Different Based on Whether the Same Surgeon or Hospital System Performs the Spine Revision?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the effects of discontinuity in care by changing surgeons, health systems, or increased time to revision surgery on revision spine fusion surgical outcomes and patient-reported outcomes.

SUMMARY OF BACKGROUND INFORMATION

Patients undergoing revision spine fusion experience worse outcomes than those undergoing primary lumbar surgery. Those requiring complex revisions are often transferred to tertiary or quaternary referral centers under the assumption that those institutions may be more accustomed at performing those procedures. However, there remains a paucity of literature assessing the impact of discontinuity of care in revision spinal fusions.

METHODS

Patients who underwent revision 1-3 level lumbar spine fusion 2011-2021 were grouped based on (1) revision performed by the index surgeon versus a different surgeon, (2) revision performed within the same versus different hospital system as the index procedure, and (3) length of time from index procedure. Multivariate regression for outcomes controlled for confounding differences.

RESULTS

A total of 776 revision surgeries were included. An increased time interval between the index procedure and the revision surgery was predictive of a lower risk for subsequent revision procedure (odds ratio: 0.57, P =0.022). Revision surgeries performed by the same surgeon predicted a reduced length of hospital stay (β: -0.14, P =0.001). Neither time to revision nor undergoing by the same surgeon or same practice predicted 90-day readmission rates. Patients are less likely to report meaningful improvement in Mental Component Score-12 or Physical Component Score-12 if revision surgery was performed at a different hospital system.

CONCLUSIONS

Patients who have revision lumbar fusions have similar clinical outcomes regardless of whether their surgeon performed the index procedure. However, continuity of care with the same surgeon may reduce hospital length of stay and associated health care costs. The length of time between primary and revision surgery does not significantly impact patient-reported outcomes.

LEVEL OF EVIDENCE

Level III.

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.

Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross-sectional study

OBJECTIVE

To investigate elective rates of spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions, by funding type (public, private, workers' compensation).

DESIGN, SETTING

Cross-sectional study; analysis of hospitals admissions data extracted from the New South Wales Admitted Patient Data Collection.

PARTICIPANTS

All adults who underwent elective spinal surgery (spinal fusion, decompression, disc replacement) in NSW, 1 July 2001 - 30 June 2020.

MAIN OUTCOME MEASURES

Crude and age- and sex-adjusted procedure rates, by procedure, funding type, and year; annual change in rates, 2001-20, expressed as incidence rate ratios (IRRs).

RESULTS

During 2001-20, 155 088 procedures in 129 525 adults were eligible for our analysis: 53 606 fusion, 100 225 decompression, and 1257 disc replacement procedures. The privately funded fusion procedure rate increased from 26.6 to 109.5 per 100 000 insured adults (per year: IRR, 1.06; 95% confidence interval [CI], 1.05-1.07); the workers' compensation procedure rate increased from 6.1 to 15.8 per 100 000 covered adults (IRR, 1.04; 95% CI, 1.01-1.06); the publicly funded procedure rate increased from 5.6 to 12.4 per 100 000 adults (IRR, 1.03; 95% CI, 1.01-1.06), and from 10.5 to 22.1 per 100 000 adults without hospital cover private health insurance (IRR, 1.03; 95% CI, 1.01-1.05). The privately funded decompression procedure rate increased from 93.4 to 153.6 per 100 000 people (IRR, 1.02; 95% CI, 1.01-1.03); the workers' compensation procedure rate declined from 19.7 to 16.7 per 100 000 people (IRR, 0.98; 95% CI, 0.96-0.99), and the publicly funded procedure rate did not change significantly. The privately funded disc replacement procedure rate increased from 6.2 per million in 2010-11 to 38.4 per million people in 2019-20, but did not significantly change for the other two funding groups. The age- and sex-adjusted rates for privately and publicly funded fusion and decompression procedures were similar to the crude rates.

CONCLUSIONS

Privately funded spinal surgery rates continue to be larger than for publicly funded procedures, and they have also increased more rapidly. These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Importance

Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.

Objective

To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.

Design, Setting, and Participants

This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.

Main Outcome and Measure

The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.

Results

Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001).

Conclusions and Relevance

In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study

BACKGROUND

The addition of fusion surgery to the decompression for lumbar degenerative disorders remains controversial. The purpose of this study is to compare the rate and outcome of decompression and fusion versus decompression alone.

METHODS

This population-based retrospective cohort study used several linked administrative databases to identify patients who underwent spinal decompression surgery in Ontario, Canada, from 2006 to 2015. Patients who had previous spine surgery, concurrent lumbar disc replacement, or a diagnosis other than degenerative disc disease were excluded. Adjusted logistic regression was used to assess our outcomes.

RESULTS

We identified 33,912 patients, of whom 9748 (28.74%) underwent fusion. Overall, fusion rates increased from 27.66% to 31.33% over the study period (P = 0.025). Factors associated with fusion included: older age, female sex, American Society of Anesthesiologists score ≥3, previous total joint replacement, and surgery by an orthopedic surgeon. Fusion surgery was associated with increased odds of 30-day mortality (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.01-3.09; P = 0.046), 30-day (OR 1.94, 95% CI 1.53-2.46; P < 0.0001) and 90-day reoperation (OR 1.66, 95% CI 1.35-2.05; P < 0.0001), and 30-day readmission (OR 1.23, 95% CI 1.02-1.49; P = 0.027) when adjusting for confounding variables. The odds of suffering a complication after fusion and decompression surgery vs. decompression surgery alone were 4.3-fold greater (95% CI 3.78-5.09; P < 0.0001).

CONCLUSIONS

As compared with decompression alone, spinal fusion for degenerative lumbar disorders is associated with increased odds of adverse outcomes. These findings highlight the need for spine surgeons to consider carefully their indications for fusion procedures in the setting of degenerative spinal disorders.

Symptomatic Postoperative Epidural Hematoma in the Lumbar Spine

A symptomatic postoperative epidural hematoma (SPEH) in the lumbar spine is a complication with variable presentation and the potential to rapidly cause an irrecoverable neurological injury. Significant heterogeneity exists among current case series reporting SPEH in the literature. This review attempts to clarify the known incidence, risk factors, and management pearls. Currently, literature does not support the efficacy of subfascial drains in reducing the incidence of SPEHs and possibly suggests that medication for thromboembolism prophylaxis may increase risk. Acute back pain and progressing lower extremity motor weakness are the most common presenting symptoms of SPEH. Magnetic resonance imaging is the mainstay of diagnostic imaging necessary to confirm the diagnosis, but if not acutely available, an immediate return to the operative theater for exploration without advanced imaging is justified. Treatment of a SPEH consists of emergent hematoma evacuation as a delay in repeat surgery has a deleterious effect on neurological recovery. Outcomes are poorly defined, though a significant portion of patients will have lasting neurological impairments even when appropriately recognized and managed.

Performance of Artificial Intelligence-Based Algorithms to Predict Prolonged Length of Stay after Lumbar Decompression Surgery

Background: Decompression of the lumbar spine is one of the most common procedures performed in spine surgery. Hospital length of stay (LOS) is a clinically relevant metric used to assess surgical success, patient outcomes, and socioeconomic impact. This study aimed to investigate a variety of machine learning and deep learning algorithms to reliably predict whether a patient undergoing decompression of lumbar spinal stenosis will experience a prolonged LOS. Methods: Patients undergoing treatment for lumbar spinal stenosis with microsurgical and full-endoscopic decompression were selected within this retrospective monocentric cohort study. Prolonged LOS was defined as an LOS greater than or equal to the 75th percentile of the cohort (normal versus prolonged stay; binary classification task). Unsupervised learning with K-means clustering was used to find clusters in the data. Hospital stay classes were predicted with logistic regression, RandomForest classifier, stochastic gradient descent (SGD) classifier, K-nearest neighbors, Decision Tree classifier, Gaussian Naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), multilayer perceptron artificial neural network (MLP), and radial basis function neural network (RBNN) in Python. Prediction accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors. Further, we developed a decision tree based on the Chi-square automatic interaction detection (CHAID) algorithm to investigate cut-offs of predictors for clinical decision-making. Results: 236 patients and 14 feature variables were included. K-means clustering separated data into two clusters distinguishing the data into two patient risk characteristic groups. The algorithms reached AUCs between 67.5% and 87.3% for the classification of LOS classes. Feature importance analysis of deep learning algorithms indicated that operation time was the most important feature in predicting LOS. A decision tree based on CHAID could predict 84.7% of the cases. Conclusions: Machine learning and deep learning algorithms can predict whether patients will experience an increased LOS following lumbar decompression surgery. Therefore, medical resources can be more appropriately allocated to patients who are at risk of prolonged LOS.

Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis

IMPORTANCE

Only limited data derived from large prospective cohort studies exist on the incidence of revision surgery among patients who undergo operations for degenerative lumbar spinal stenosis (DLSS).

OBJECTIVE

To assess the cumulative incidence of revision surgery after 2 types of index operations-decompression alone or decompression with fusion-among patients with DLSS.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from a multicenter, prospective cohort study, the Lumbar Stenosis Outcome Study, which included patients aged 50 years or older with DLSS at 8 spine surgery and rheumatology units in Switzerland between December 2010 and December 2015. The follow-up period was 3 years. Data for this study were analyzed between October and November 2021.

EXPOSURES

All patients underwent either decompression surgery alone or decompression with fusion surgery for DLSS.

MAIN OUTCOMES AND MEASURES

The primary outcome was the cumulative incidence of revision operations. Secondary outcomes included changes in the following patient-reported outcome measures: Spinal Stenosis Measure (SSM) symptom severity (higher scores indicate more pain) and physical function (higher scores indicate more disability) subscale scores and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire (EQ-5D-3L) summary index score (lower scores indicate worse quality of life).

RESULTS

A total of 328 patients (165 [50.3%] men; median age, 73.0 years [IQR, 66.0-78.0 years]) were included in the analysis. Of these, 256 (78.0%) underwent decompression alone and 72 (22.0%) underwent decompression with fusion. The cumulative incidence of revisions after 3 years of follow-up was 11.3% (95% CI, 7.4%-15.1%) for the decompression alone group and 13.9% (95% CI, 5.5%-21.5%) for the fusion group (log-rank P = .60). There was no significant difference in the need for revision between the 2 groups over time (unadjusted absolute risk difference, 2.6% [95% CI, -6.3% to 11.4%]; adjusted absolute risk difference, 3.9% [95% CI, -5.2% to 17.0%]; adjusted hazard ratio, 1.40 [95% CI, 0.63-3.13]). The number of revisions was significantly associated with higher SSM symptom severity scores (β, 0.171; 95% CI, 0.047-0.295; P = .007) and lower EQ-5D-3L summary index scores (β, -0.061; 95% CI, -0.105 to -0.017; P = .007) but not with higher SSM physical function scores (β, 0.068; 95% CI, -0.036 to 0.172; P = .20). The type of index operation was not significantly associated with the corresponding outcomes.

CONCLUSIONS AND RELEVANCE

This cohort study showed no significant association between the type of index operation for DLSS-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life.

Stability of SF-36 profiles between 2007 and 2016: A study of 27,302 patients surgically treated for lumbar spine diseases

Background

Previous studies have shown that patients with different lumbar spine diseases report different SF-36 profiles, but data on the stability of the SF-36 profiles are limited. The primary aim of the current study was to evaluate the stability of the SF-36 profile for lumbar spine diseases.

Methods

Patients, surgically treated between 2007 and 2016 for three lumbar spine diseases, lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS), LSS without DS, and lumbar disk herniations (LDH), were identified in the Swedish spine register. Preoperative and 1 year postoperative SF-36 data for a total of 27,302 procedures were available for analysis. The stability of the SF-36 profiles over the 10-year period was evaluated using graphical exploration, linear regression, difference in means, and 95% confidence intervals. The responsiveness of the SF-36 domains to surgical treatment was evaluated using the standardized response mean (SRM).

Results

LSS and LDH have different SF-36 profiles. LSS with DS and LSS without DS have similar SF-36 profiles. The preoperative and the 1 year postoperative SF-36 profiles were stable from 2007 to 2016 for all three diagnoses. There were no major changes in the effect size of change (SRM) during the study period for all three diagnoses. For LSS with DS, the number of fusions peaked in 2010 and then decreased. The postoperative SF-36 profiles for LSS with DS were unaffected by changes in surgical treatment trends.

Conclusions

Patients with lumbar spinal stenosis and lumbar disk herniations have different SF-36 profiles. Concomitant degenerative spondylolisthesis had no impact on the SF-36 profile of lumbar spinal stenosis. Adding fusion to the decompression did not alter the postoperative SF-36 profile of lumbar spinal stenosis. The SF-36 health profiles are stable from a 10 years perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01999-7.

The effectiveness of percutaneous endoscopic decompression compared with open decompression and fusion for lumbar spinal stenosis: protocol for a multicenter, prospective, cohort study

Background

Lumbar spinal stenosis (LSS) is one of the most frequent indications for spine surgery. Open decompression and fusion surgery was the most common treatment and used to be regarded as the golden standard treatment for LSS. In recent years, percutaneous endoscopic decompression surgery was also used for LSS. However, the effectiveness and safety of percutaneous endoscopic decompression in the treatment of LSS have not been supported by high-level evidence. Our aim is to 1) compare the effectiveness of percutaneous endoscopic decompression surgery and open decompression and fusion for the treatment of LSS. 2) Investigate the prognosis risk factors for LSS. 3) Evaluate the influence of percutaneous endoscopic decompression for the stability of operative level, and degeneration of adjacent level.

Methods

It’s a prospective, multicenter cohort study. The study is performed at 4 centers in Beijing. This study plans to enroll 600 LSS patients (300 patients in the percutaneous endoscopic decompression group, and 300 patients in the open decompression and fusion group). The demographic variables, healthcare variables, symptom related variables, clinical assessment (Visual analogue score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association score (JOA)), and radiological assessment (dynamic X-ray, CT, MRI) will be collected at baseline visit. Patients will follow up at 3, 6, 12 months. The primary outcome is the difference of improvement of ODI between baseline and 12-month follow-up between the two groups. The secondary outcome is the score changes of preoperative and postoperative VAS, the recovery rate of JOA, MacNab criteria, patient satisfaction, degeneration grade of adjacent level, ROM of operative level and adjacent level, complication rate.

Discussion

In this study, we propose to conduct a prospective registry study to address the major controversies of LSS decompression under percutaneous spinal endoscopy, and investigate the clinical efficacy and safety of percutaneous endoscopic decompression and open decompression in the treatment of LSS.

Trial registration

This study has been registered on clinicaltrials.gov in January 15, 2020 (NCT04254757). (SPIRIT 2a).

Clinical Evaluation of Paraspinal Mini-Tubular Lumbar Decompression and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spondylolisthesis Grade I with Lumbar Spinal Stenosis: A Cohort Study

Objective

To investigate the clinical outcome data and difference in efficacy between paraspinal mini-tubular lumbar decompression (PMTD) and minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the treatment of degenerative lumbar spondylolisthesis grade I with lumbar spinal stenosis (DLS-I-LSS).

Methods

Patients with DLS-I-LSS, who underwent PMTD or MIS TLIF from September 2017 to March 2020, were included retrospectively. The follow-up period was 24 months after surgery. Outcome measurements included the Oswestry disability index (ODI) score, visual analog scale (VAS) low back pain score, VAS leg pain score, surgical data, and adverse events.

Results

A total of 104 patients with DLS-I-LSS were included in this study. The average improvement in ODI at 12 months (2.0%, 95% CI, −5.7% to 1.8%; p = 0.30) and 24 months (1.7%, 95% CI, −2.7% to 6.1%; p = 0.45) after surgery between the two groups were not statistically significant. The improvement in VAS low back pain score after 24 months and improvement in VAS leg pain score were not significantly different between the two groups. Compared with the PMTD group, the MIS TLIF group had more estimated blood loss and longer hospital stays. The cumulative reoperation rates were 5.66% and 1.96% in the MIS TLIF and PMTD groups, respectively (p = 0.68). The results of multivariate analysis showed that BMI, diabetes, and baseline ODI score were the main factors influencing the improvement in ODI in patients with DLS-I-LSS after minimally invasive surgery, accounting for 50.5% of the total variance.

Conclusions

The clinical effectiveness of PMTD was non-inferior to that of MIS TLIF for DLS-I-LSS; however, there was a reduced duration of hospital stay, operation time, blood loss, and hospitalization costs in the PMTD group. BMI, presence or absence of diabetes and baseline ODI score were influencing factors for the improvement of ODI (Trial Registration: ChiCTR2000040025).

Mid-term changes in spinopelvic sagittal alignment in lumbar spinal stenosis with coexisting degenerative spondylolisthesis or scoliosis after minimally invasive lumbar decompression surgery: minimum five-year follow-up

BACKGROUND CONTEXT

Recently, the number of patients with lumbar spinal stenosis (LSS) who present with a coexisting spinal deformity such as degenerative spondylolisthesis (DS) and scoliosis (DLS) has been increasing. Lumbar decompression without fusion can lead to a reactive improvement in the lumbar and sagittal spinopelvic alignment, even if a sagittal imbalance exists preoperatively. However, the mid- to long-term impact of the coexistence of DS and DLS on the change in sagittal spinopelvic alignment and clinical outcomes after decompression surgery remains unknown.

PURPOSE

This study aimed to investigate whether the coexistence of DS or DLS in patients with LSS is associated with differences in radiological and clinical outcomes after minimally invasive lumbar decompression surgery.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

A total of 169 patients who underwent minimally invasive lumbar decompression surgery and follow-up >5 years postoperatively.

OUTCOME MEASURES

Self-report measures: Low back pain (LBP) and/or leg pain and/or leg numbness visual analog scale (VAS) scores and the Japanese Orthopedic Association scores.

PHYSIOLOGIC MEASURES

Standing sagittal spinopelvic alignment.

METHODS

In total, 81 patients with LSS, 50 patients with LSS and DS (≥3 mm anterior slippage), and 38 patients with LSS and DLS (≥15° coronal Cobb angle) were included in the current study. Clinical and radiological outcome results before surgery and at 2 and 5 years after surgery were compared among the groups.

RESULTS

In patients with LSS with coexisting DS, the clinical outcomes at 2, and 5 years after surgery were similar to those of patients with only LSS. In patients with LSS with coexisting DLS, the VAS LBP and leg pain at 2 years after surgery was significantly higher (34.7 vs. 27.8, p=0.014; 27.8 vs. 14.7, p=0.028) and the achievement rate of the minimal clinically important difference in VAS LBP and leg pain was significantly lower than that of the LSS group (36.1% vs. 54.2%, p=0.036; 58.3% vs. 69.9%, p=0.10). The clinical outcomes except VAS leg numbness at 5 years after surgery were similar to those of patients with only LSS. The reoperation rate of the DS group was significantly lower than that of the LSS group (4.0% vs. 14.8%; p=0.01); however, the reoperation rate of the DLS group was comparable to that of the LSS group (15.8% vs. 14.8%; p=0.493). Lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence-LL had significantly improved and been maintained for 5 years after the surgery in both the DS and the DLS groups. The sagittal vertical axis had improved at two-year follow-up; however, no significant difference was observed at the 5-year follow-up in both the DS, and the DLS groups.

CONCLUSIONS

Mid-term clinical outcomes in patients with LSS with and without deformity were comparable. Lumbar decompression without fusion can result in a reactive improvement in the lumbar and sagittal spinopelvic alignment, even with coexisting DS or DLS. Minimally invasive surgery could be considered for most patients with LSS.

No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis: Results From the National Swedish Spine Registry 2-Year Post-Op

STUDY DESIGN

Observational cohort study.

OBJECTIVE

The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear.

METHODS

All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery.

RESULTS

Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64).

CONCLUSION

In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.Level of Evidence: 3.

Lumbar Spinal Stenosis with Degenerative Spondylolisthesis Treated with Decompression Alone. A Cohort of 346 Patients at a Large Spine Unit. Clinical Outcome, Complications and Subsequent Surgery

STUDY DESIGN

Cohort study.

OBJECTIVE

To study the clinical outcome, complications and subsequent surgery rate of DA for lumbar spinal stenosis (LSS) with DS.

SUMMARY OF BACKGROUND DATA

There is still no consensus regarding the treatment approach for LSS with DS.

METHODS

We performed a retrospectively designed cohort study on prospectively collected data from a single high productive spine surgical center. Results from the Swedish Spine Registry and a local register for complications were used for the analyses. Patients with LSS and DS (>3 mm) who underwent DA during January 2012 to August 2017 were included. Patient reported outcome measures at baseline and 2 years after surgery were analyzed. Complications within 30 days of surgery and all subsequent surgery in the lumbar spine were registered.

RESULTS

We identified and included 346 patients with completed 2-year follow-up registration. At 2-year follow-up there was a significant improvement in all outcome measures. The global assessment success rate for back and leg pain was 68.3% and 67.6% respectively. Forty-one patients had at least 1 intra- or postoperative complication (11.9%). Nine patients (2.6%), underwent subsequent surgery within 2 years of the primary surgery whereof 2 underwent fusion. During the whole period of data collection, that is, as of June 2020, 28 patients had undergone subsequent surgery (8.1%) whereas 8 of them had had 2 surgeries. Fifteen patients underwent fusion.

CONCLUSION

DA provides good clinical outcome at 2-year follow-up in patients with LSS and DS with low rate of intra- and postoperative complications and subsequent surgery. Our data supports the evidence that DA is effective and safe for LSS with DS.Level of Evidence: 3.

Clinical outcome following decompression and short or long instrumented fusion in lumbar degenerative spinal stenosis. A prospective case-control analysis

OBJECTIVES

There is limited data on the direct clinical comparison between short and long fusion following surgery for lumbar spinal stenosis. The hypothesis that regardless their baseline characteristics and morbidity, clinical outcome is similar in patients with lumbar stenosis treated with decompression plus posterior instrumented fusion in one or two versus three to five levels was tested.

METHODS

Subjects were divided into Group A and Group B corresponding to stenotic pathology and instrumented fusion in one or two levels and three to five levels, respectively. Primary outcome measures at one year were the change in SF-36 physical component (PCS) and Oswestry Disability Index (ODI). Secondary outcome measures included the EuroQol-5D (EQ-5D), the Visual Analog Scale (VAS), the mental component (MCS) of SF-36 scale and the Zung Self-Rating Depression Scale.

RESULTS

Seventy seven (77) patients were included (Group A, n = 42; Group B, n = 35). Patients in Group B were older, surgery lasted longer and intraoperative blood loss was greater than patients in Group A (p < 0.05). A significant clinical improvement was noted in both Groups on all scales (p < 0.01). Clinical outcome at one year was equally favorable in both Groups (p > 0.05). The evaluation of depression for Group A showed a significant improvement at one year (p = 0.02) compared to the preoperative status.

CONCLUSIONS

Older individuals are more likely to have multilevel stenosis and more co-morbidities and they were associated with longer instrumentation. However, complications are similar and clinical outcome is equally favorable compared to short instrumented fusion for fewer levels of disease.

Revision pedicle screws with impaction bone grafting: a case series

BACKGROUND

Pedicle screw fixation in spinal constructs can be subject to failure requiring revision surgery. In cases of aseptic loosening various salvage techniques have been described. Revision screws augmented with cement have become popular but are not without risks. Larger diameter screws are often used but result in reducing bone stock or expanding the pedicles. We present a novel technique of pedicle screw revision by impaction bone allografting and a case series.

METHODS

The failed screws are removed. The screw track is probed to check its integrity. Milled bone allograft is funneled into the screw hole and sequentially impacted, before insertion of a replacement screw. We report a case series and describe a single case where this method has been used. Information was gathered from the electronic patient record in our hospital.

RESULTS

Ten screws were revised in 7 patients. Mean age at first surgery was 60.86 (48-76) years. Average time between first surgery and revision was 12.6 (4.7-49.9) months. Average follow-up was 26.2 (5.7-62.2) months and no screws showed any signs of loosening.

CONCLUSIONS

Impaction grafting with bone allograft is a technique for pedicle screw salvage that can be used safely and effectively as an alternative to cemented screws, when pedicle screws have failed by aseptic loosening. It avoids the risks associated with cemented screws and in our series was successful.

Best versus worst surgical outcomes after single-level posterior lumbar interbody fusion for degenerative spondylolisthesis

PURPOSE

Previous studies have shown conflicting results regarding the factors affecting the clinical outcome after fusion for degenerative spondylolisthesis. However, no study has compared the best and worst clinical outcome groups using patient-reported outcome measures. We aimed to compare the characteristics of patients with best and worst outcomes following single-level lumbar fusion for degenerative spondylolisthesis.

METHODS

200 patients underwent single-level interbody fusion with a minimum 2-years follow-up were included. We excluded patients with surgical complications already-known to be associated with poor postoperative outcomes, including pseudoarthrosis and postoperative infection. According to 2-year postoperative Oswestry disability index scores, patients were divided into two groups; Best and Worst. Demographic, clinical and radiographic variables were compared between the two groups.

RESULTS

Compared with patients in the Best group, those in the Worst group were older (59.5 and 67.0 years, respectively; p = 0.012; odds ratio [OR], 1.143; 95% confidence interval [CI], 1.030-1.269) and had a longer duration of pain from onset (2.6 and 7.2 years, respectively; p = 0.041; OR, 1.021; 95% CI, 1.001-1.041). The cutoff value of pain duration from onset was measured as ≥3.5 years on Receiver operating characteristic analysis. Patients in the Worst group had a lower preoperative angular motion compared to those in the Best group (12.7° and 8.3°, respectively; p = 0.016; OR, 0.816; 95% CI, 0.691-0.963).

CONCLUSIONS

Degenerative spondylolisthesis patients of good clinical outcome after single-level lumbar interbody fusion were relatively young, had a short symptom duration before surgery, and a high preoperative instability compared with the patient having poor postoperative clinical outcome. Therefore, these findings should be considered preoperatively when deciding the appropriate individual treatment plan.

Immediate postoperative MRI findings after lumbar decompression surgery: Correlation of imaging features with clinical outcome

An understanding of the common MRI findings observed after decompression surgery is important. However, to date, no study addressing this has been published. The aim of this study was to analyze and describe the immediate postoperative MRI findings after lumbar decompression surgery. We retrospectively analyzed the immediate postoperative MRIs of 121 consecutive patients who underwent lumbar decompression surgery between July 2017 and June 2018. Changes in stenosis at the decompressed and adjacent levels, epidural fat edema, epidural and subdural fluid collections, nerve root swelling, facet joint effusions, intervertebral disc signal, and paravertebral muscle edema were correlated with clinical characteristics. Both groups had reduced central canal stenosis postoperatively (p < 0.001) but worsened stenosis at adjacent segments. Fluid collection, hemorrhagic or non-hemorrhagic, at the laminectomy site was the commonest finding (one-level: 73.8%, two-level: 88.5%), with a higher percentage of severe central canal compromise in the two-level decompression group (p = 0.003). Other postoperative MRI findings, such as epidural fat edema, nerve root swelling, subdural fluid collection, and facet joint effusion, were noted without statistical significance. In conclusion, even with successful decompression for lumbar canal stenosis, increased central canal stenosis at adjacent segments is common on immediate postoperative MRI scans, showing no statistically significant correlation with the immediate postoperative outcome. Postoperative fluid collection at the laminectomy site is the commonest imaging finding, and higher rates of hemorrhagic fluid and more severe central canal compromise occur in two-level decompression, but rarely cause clinical problems.

A Retrospective Cohort Study of Effects of Antihypertensive and Anticholinergic Medications on Outcomes Following Elective Posterior Lumbar Spine Surgery

STUDY DESIGN

This was a retrospective consecutive cohort analysis.

OBJECTIVE

This study aimed to examine the association between commonly prescribed medications and outcomes following posterior lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Postoperative complications and prolonged length of stay significantly increase costs following posterior lumbar spine surgery and worsen patient outcomes. To control costs and complications, providers should focus on modifiable risk factors, such as preoperative medications. Antihypertensive and anticholinergic drugs are among the most commonly prescribed medications but can carry significant risks in the perioperative period.

MATERIALS AND METHODS

This study was a retrospective cohort analysis of patients undergoing posterior lumbar spine surgery from January 2014 through December 2015 at a large tertiary care center. The variable selection followed by multivariable logistic and negative binomial regressions were performed. An α threshold of 0.0056 was used for significance after correction for multiple comparisons. A secondary analysis was performed to evaluate confounding or effect modifying variables.

RESULTS

This study included 1577 patients. Postoperative urinary retention risk was increased in patients taking loop diuretics. Acute kidney injury risk was increased for patients on nondihydropyridine calcium-channel blockers. Surgical site infection risk was increased for patients on aldosterone receptor blockers. Urinary tract infection risk was increased for patients on anticholinergics for urinary incontinence. Length of stay was decreased for patients on angiotensin II antagonists and angiotensin-converting enzyme inhibitors.

CONCLUSION

A care path should be established in the perioperative period for patients who are deemed to be at higher risk due to medication status to either modify medications or improve postoperative monitoring.

LEVEL OF EVIDENCE

Level III.

Full-Endoscopic Lumbar Decompression versus Open Decompression and Fusion Surgery for the Lumbar Spinal Stenosis: A 3-Year Follow-Up Study

Purpose

Compare the efficacy of full-endoscopic lumbar decompression surgery (FELDS) and open decompression and fusion surgery (ODFS) for lumbar spinal stenosis (LSS).

Patients and Methods

A retrospective analysis of 358 LSS patients treated by FELDS (“FELD” group) or ODFS (“open” group) was undertaken. There were 177 patients in the FELDS group with a mean age of 65.47±9.26 years and 181 patients in the open group with a mean age of 64.18±10.24 years. Duration of follow-up was 38.63±11.88 months in the FELDS group and 38.56±12.29 months in the open group. Visual analog scale (VAS) score, Oswestry Disability Index (ODI), and Modified MacNab criteria were used to access clinical outcomes. Surgical outcomes (duration of surgical procedure, blood loss, complications, duration of postoperative hospital stay (DOPHS), prevalence of revision procedures) were evaluated. Magnetic resonance imaging was used to evaluate the change in the Pfirrmann grade at adjacent segments.

Results

VAS score (leg and back) and ODI improved significantly in both groups (P<0.001). Success rate reached 86.55% and 90.60% in the FELDS group and open group (P>0.05), respectively. Procedure duration (84.12 vs 112.08 min), blood loss (7.97 vs 279.67 mL), and DOPHS (2.68 vs 4.78 days) of the FELDS group were significantly better than those of the open group (P<0.05). Total prevalence of complications and procedure revisions was 14.69% and 10.73% in the FELD group, respectively, but did not show a significant difference with that in the open group (12.15% and 9.39%, respectively). The Pfirrmann grade increased in 13.04% of adjacent segments in the FELDS group, significantly better than that in the open group (32.67%) (P<0.05).

Conclusion

FELDS had the same efficacy as ODFS for LSS treatment. FELDS had the advantages of minimal invasiveness, less surgical trauma, rapid recovery, and lower risk of degeneration of adjacent segments compared with that of ODFS.

Effect of lumbar laminectomy on spinal sagittal alignment: a systematic review

PURPOSE

Positive spinal sagittal alignment is known to correlate with pain and disability. The association between lumbar spinal stenosis and spinal sagittal alignment is less known, as is the effect of lumbar decompressive surgery on the change in that alignment. The objective was to study the evidence on the effect of lumbar decompressive surgery on sagittal spinopelvic alignment.

METHODS

The Cochrane Controlled Trials Register (CENTRAL), Medline, Embase, Scopus and Web of Science databases were searched in October 2019, unrestricted by date of publication. The study selection was performed by two independent reviewers. The risk of systematic bias was assessed according to the NIH Quality Assessment Tool. The data were extracted using a pre-defined standardized form.

RESULTS

The search resulted in 807 records. Of these, 18 were considered relevant for the qualitative analysis and 15 for the meta-synthesis. The sample size varied from 21 to 89 and the average age was around 70 years. Decompression was mostly performed on one or two levels and the surgical techniques varied widely. The pooled effect sizes were most statistically significant but small. For lumbar lordosis, the effect size was 3.0 (95% CI 2.2 to 3.7) degrees. Respectively, for pelvic tilt and sagittal vertical axis, the effect sizes were - 1.6 (95% CI .2.6 to - 0.5) degrees and - 9.6 (95% CI - 16.0 to - 3.3) mm.

CONCLUSIONS

It appears that decompression may have a small, statistically significant but probably clinically insignificant effect on lumbar lordosis, sagittal vertical axis and pelvic tilt.

Physiotherapy utilisation and costs before lumbar spine surgery: a retrospective analysis of workers compensation claims in Australia

Background

Understanding how much physiotherapy people receive before lumbar spine surgery could give insight into what people and clinicians consider an adequate trial of non-operative management. The aim of this study was to investigate physiotherapy utilisation and costs before lumbar spine surgery under a workers’ compensation claim in New South Wales (NSW), Australia.

Methods

Using data from the NSW State Insurance Regulatory Authority, we audited physiotherapy billing codes used before surgery for people who received lumbar spine surgery from 2010 to 2018. We summarised, separately for fusion and decompression, the time from initiation of physiotherapy to surgery, number of physiotherapy sessions people received before surgery, total cost of physiotherapy before surgery, and time from injury date to initiation of physiotherapy. All analyses were descriptive.

Results

We included 3070 people (800 had fusion, 2270 decompression). Mean age (standard deviation, SD) was similar between those who received fusion and decompression [42.9 (10.4) vs. 41.9 (11.6)]. Compared to people who had fusion, those who had decompression were more likely to not have any physiotherapy before surgery (28.4% vs. 15.4%), received physiotherapy for a shorter duration before surgery [median (interquartile range, IQR): 5 (3 to 11) vs. 15 (4–26) months], were less likely to have physiotherapy for ≥2 years before surgery (5.6% vs. 27.5%), had fewer physiotherapy sessions before surgery [mean (SD): 16 (21) vs. 28 (35) sessions], were less likely to have > 50 physiotherapy sessions before surgery (6.8% vs. 18.1%), and had lower total physiotherapy-related costs [mean (IQR): $1265 ($0–1808) vs. $2357 ($453–2947)]. Time from injury date to first physiotherapy session was similar between people who had fusion and decompression [median (IQR): 23 (9–66) vs.19 (7–53) days].

Conclusions

There is variation in physiotherapy utilisation and costs before lumbar spine surgery for people funded by NSW Workers’ Compensation. Some people may not be receiving an adequate trial of physiotherapy before surgery, particularly before decompression surgery. Others may be receiving an excessive amount of physiotherapy before surgery, particularly before fusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04129-4.

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.

Nationwide Analysis of Lower Extremity Periprosthetic Fractures

BACKGROUND

Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States.

METHODS

Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups.

RESULTS

The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P_trend = .97) with an increase in total hip arthroplasty (THA) revision (P_trend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P_trend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both).

CONCLUSION

The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.

The effect of age and gender on acute postoperative pain and function following lumbar spine surgeries

BACKGROUND AND PURPOSE

Understanding the factors contributing to the variability in postoperative pain and function following lumbar spine surgeries (LSS) is necessary to plan inpatient rehabilitation and optimize surgical outcomes. In particular, variability due to age and gender has not been studied. This study's aim was to evaluate the variability in postoperative pain and function, during hospital stay, due to age and gender following LSS.

METHODS

We conducted a retrospective analysis of 585 patients who underwent LSS during their hospital stay. Univariate ANCOVA was performed to study the differences in postoperative pain, and multivariate ANCOVA was performed to study the differences in postoperative function (gait distance, independency combined score, and balance combined score) between age groups (older adults [≥65 years of age] vs. younger adults) and gender.

RESULTS

Younger patients reported statistically, but not clinically, significant higher postoperative pain than older patients (β = 0.652 [95% CI (0.382-0.986)], p < 0.001), and males reported statistically, but not clinically, significant lower postoperative pain than female patients (β = -0.583 [95% CI (-0.825 to -0.252)], p < 0.001) with adjustment of covariates. Male patients walked significantly longer distance than female patients (β = 0.272 [95% CI (0.112-0.432)], p = 0.001) with adjustment of covariates. However, these were clinically insignificant. With adjustment of preoperative diagnosis, type of surgery, severity of illness, and prior level of function, there was no statistically significant difference between age groups in walking distance, and between age and gender groups in independency combined score and balance combined scores.

DISCUSSION

Following LSS, the difference in postoperative pain between age groups and gender are statistically but not clinically significant, suggesting patients require similar effective postoperative pain management regardless of age and gender. The apparent difference in age and gender in postoperative functional outcomes could be due to other factors.

Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome-Experience with 1001 Patients

BACKGROUND

Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing.

METHODS

A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery.

RESULTS

Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome.

CONCLUSIONS

Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m², symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.

A comparative study of Lumbar Decompression and Fusion with Internal Fixation versus Simple Decompression in elderly patients with two-segment Lumbar Spinal Stenosis

Objective:

To investigate and compare the effect of decompression and fusion with internal fixation vs. simple decompression in the treatment of elderly patients with two-segment lumbar spinal stenosis (LSS) in perioperative and postoperative follow-up periods.

Methods:

Twenty-eight elderly patients with two-segment LSS admitted in Baoding First Hospital between Mar. 2017 and Jan. 2018 were retrospectively analyzed. Fifteen patients who underwent simple decompression were included in the simple decompression group, and 13 who underwent decompression and fusion with internal fixation were included in the decompression-fixation group. The general data and perioperative conditions including wound complications, operation time, blood loss, and VAS (legs) and JOA score were analyzed and compared between the two groups.

Results:

There was no significant difference in postoperative leg pain (VAS) between the two groups, and a statistically significant difference in JOA score was found between the two groups one month after the operation. The operation time, length of stay, and blood loss in the decompression-fixation group were significantly different from those in the simple decompression group and no significant difference in wound complications was observed between the two groups.

Conclusion:

There is no significant difference in leg pain relief in elderly patients with two-segment LSS when treated with decompression and fusion with internal fixation or simple decompression. Simple decompression is associated with less intraoperative injuries, better postoperative functional recovery, and reduced hospital stay.

Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution

BACKGROUND

Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients.

METHODS

Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications.

RESULTS

A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance.

CONCLUSIONS

These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.

Trends in lumbar spinal fusion-a literature review

Over the past several decades, there has been an upward trend in the total number of spinal fusion procedures worldwide. Advanced spinal fusion techniques with or without internal fixation, additional innovations in surgical approaches, innovative implants including a wide variety of interbody devices, and new alternatives in bone grafting materials are some reasons for the increasing number of spine fusion procedures. Moreover, the indications for spinal fusion have broadened over time. Initially developed for the treatment of instability and deformity due to tuberculosis, scoliosis, and traumatic injury, spinal fusion surgery has now a wide range of indications like spondylolisthesis, congenital or degenerative deformity, spinal tumors, and pseudarthrosis, with degenerative disorders as the most common indication. This review emphasizes current lumbar fusion techniques and their development in the past decades.

Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery

BACKGROUND

The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery.

METHODS

Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months.

RESULTS

After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively.

CONCLUSION

Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.

Linical efficacy of percutaneous endoscopic lumbar discectomy for the treatment of lumbar spinal stenosis in elderly patients: a retrospective study

Background

Although percutaneous endoscopic lumbar discectomy (PELD) is increasingly being used to treat lumbar degenerative disease, the treatment of elderly patients with lumbar spinal stenosis (LSS) involves considerable uncertainty. The purpose of this study was to evaluate the safety and effectiveness of PELD for the treatment of LSS in elderly patients aged 65 years or older.

Methods

In this retrospective review, 136 patients aged 65 years or older who underwent PELD to treat LSS were evaluated. The patients were divided into two groups, group A (ages 65–74) and group B (age ≥ 75), and perioperative data were analyzed. The Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and MacNab classification were used to evaluate postoperative clinical efficacy.

Results

All patients successfully underwent the operation with satisfactory treatment outcomes. Compared to preoperative scores, the self-reported scores or pain while performing daily activities were significantly improved in both treatment groups (P < 0.05). No statistically significant between-group differences were observed in operation time, intraoperative blood loss, postoperative bed rest, and postoperative hospital stay (P > 0.05). The overall postoperative complication rate was similar between the two groups. Moreover, no statistically significant differences in VAS-back pain scores, VAS-leg pain scores, JOA scores, and MacNab classification were found between the groups at the 3-month and 1.5-year follow-up examinations (P > 0.05).

Conclusion

PELD is safe and effective for the treatment of LSS in elderly patients. Age is not a contraindication for decompressive lumbar spine surgery. PELD has advantages such as reduced trauma, fewer anesthesia-related complications, and a fast postoperative recovery. Elderly patients should be considered good candidates for lumbar decompression surgery using minimally invasive techniques.

Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis

Background

One advantage of an endoscopic approach to treating lumbar spinal stenosis is preservation of spine stability and the adjacent anatomy, and there is a decrease in adjacent segment disc degeneration. The purpose of this study was to discuss the clinical efficacy of percutaneous transforaminal endoscopic decompression for the treatment of lumbar spinal stenosis (LSS).

Methods

This is a retrospective study. From September 2012 to June 2017, 45 patients who were diagnosed with LSS underwent the treatment of percutaneous transforaminal endoscopic decompression (PTED) and were followed up at 1 week, 3 months and 1 year postoperatively. Low back pain and leg pain were measured by Visual Analogue Scale scoring methods (VAS-back and VAS-leg), while functional outcomes were assessed by using the Oswestry Disability Index (ODI). All patients had one-level lumbar spinal stenosis.

Results

The most common type of stenosis was lateral recess stenosis (n = 22; 48.9%), followed by central stenosis (n = 13; 28.9%) and foraminal stenosis (n = 10: 22.2%). Regarding comparisons of VAS-back, VAS-leg, and ODI scores before and after operation, VAS and ODI scores significantly improved. The average leg VAS score improved from 7.01 ± 0.84 to 2.28 ± 1.43 (P < 0.001). The average ODI improved from 46.18 ± 10.11 to 14.40 ± 9.59 (P < 0.001). We also examined changes in ODI and VAS scores from baseline according to types of spinal stenosis, stenosis grade, spinal instability, and revision surgery in the same segment. The improvement percentage of leg VAS score was significantly less in patients with severe stenosis at both 3 months and 1 year postoperatively. The improvement percentages of ODI and leg VAS scores were significantly less in patients who had spinal instability and patients who had undergone revision surgery.

Conclusion

The PTED approach seems to give good results for the treatment of LSS. However, this approach may be less effective for LSS patients who have lumbar instability or require revision surgery in the same segment.

Interlaminar stabilization offers greater biomechanical advantage compared to interspinous stabilization after lumbar decompression: a finite element analysis

BACKGROUND

Interlaminar stabilization and interspinous stabilization are two newer minimally invasive methods for lumbar spine stabilization, used frequently in conjunction with lumbar decompression to treat lumbar stenosis. The two methods share certain similarities, therefore, frequently being categorized together. However, the two methods offer distinct biomechanical properties, which affect their respective effectiveness and surgical success.

OBJECTIVE

To compare the biomechanical characteristics of interlaminar stabilization after lumbar decompression (ILS) and interspinous stabilization after lumbar decompression (ISS). For comparison, lumbar decompression alone (DA) and decompression with instrumented fusion (DF) were also included in the biomechanical analysis.

METHODS

Four finite element models were constructed, i.e., DA, DF, ISS, and ILS. To minimize device influence and focus on the biomechanical properties of different methods, Coflex device as a model system was placed at different position for the comparison of ISS and ILS. The range of motion (ROM) and disc stress peak at the surgical and adjacent levels were compared among the four surgical constructs. The stress peak of the spinous process, whole device, and device wing was compared between ISS and ILS.

RESULTS

Compared with DA, the ROM and disc stress at the surgical level in ILS or ISS were much lower in extension. The ROM and disc stress at the surgical level in ILS were 1.27° and 0.36 MPa, respectively, and in ISS 1.51°and 0.55 MPa, respectively in extension. This is compared with 4.71° and 1.44 MPa, respectively in DA. ILS (2.06-4.85° and 0.37-0.98 MPa, respectively) or ISS (2.07-4.78° and 0.37-0.98 MPa, respectively) also induced much lower ROM and disc stress at the adjacent levels compared with DF (2.50-7.20° and 0.37-1.20 MPa, respectively). ILS further reduced the ROM and disc stress at the surgical level by 8% and 25%, respectively, compared to ISS. The stress peak of the spinous process in ILS was significantly lower than that in ISS (13.93-101 MPa vs. 31.08-172.5 MPa). In rotation, ILS yielded a much lower stress peak in the instrumentation wing than ISS (128.7 MPa vs. 222.1 MPa).

CONCLUSION

ILS and ISS partly address the issues of segmental instability in DA and hypermobility and overload at the adjacent levels in DF. ILS achieves greater segmental stability and results in a lower disc stress, compared to ISS. In addition, ILS reduces the risk of spinous process fracture and device failure.

Measuring clinically relevant improvement after lumbar spine surgery: is it time for something new?

BACKGROUND CONTEXT

Minimum clinically important difference (MCID) for patient-reported outcome measures is commonly used to assess clinical improvement. However, recent literature suggests that an absolute point-change may not be an effective or reliable marker of response to treatment for patients with low or high baseline patient-reported outcome scores. The multitude of established MCIDs also makes it difficult to compare outcomes across studies and different spine surgery procedures.

PURPOSE

To determine whether a 30% reduction from baseline in disability and pain is a valid method for determining clinical improvement after lumbar spine surgery.

STUDY DESIGN

Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.

PATIENT SAMPLE

There were 23,280 participants undergoing elective lumbar spine surgery for degenerative disease who completed a baseline and follow-up assessment at 12 months.

OUTCOME MEASURES

Patient-reported disability (Oswestry Disability Index [ODI]), back and leg pain (11-point Numeric Rating Scale [NRS]), and satisfaction (NASS scale).

METHODS

Patients completed baseline and a 12-month postoperative assessment to evaluate the outcomes of disability, pain, and satisfaction. The change in ODI and NRS pain scores was categorized as met (≥30%) or not met (<30%) percent reduction MCID. The 30% reduction from baseline was compared with a wide range of well-established absolute point-change MCID values. The relationship between 30% reduction and absolute change values and satisfaction were primarily compared using receiver operating characteristic (ROC) curves, area under the curve (AUROC), and logistic regression analyses. Analyses were conducted for overall scores and for disability and pain severity categories and by surgical procedure.

RESULTS

Thirty percent reduction in ODI and back and leg pain predicted satisfaction with more accuracy than absolute point-change values for the total population and across all procedure categories (p<.001), except for when compared with the highest absolute point-change threshold for leg pain (3.5-point reduction). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 21.8%) and bed-bound disability (ODI 81%-100%: 13.9%) categories. For pain, there was a 3.4%-12.4% and 1.3%-9.8% AUROC difference for no/mild back and leg pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.

CONCLUSIONS

A 30% reduction MCID either outperformed or was similar to absolute point-change MCID values. Results indicate that a 30% reduction (baseline to 12 months after surgery) in disability and pain is a valid method for determining clinically relevant improvement in a broad spine surgery population. Furthermore, a 30% reduction was most accurate for patients in the lowest and highest disability and lowest pain severity categories. A 30% reduction MCID allows for a standard cut-off for disability and pain that can be used to compare outcomes across various spine surgery procedures.

Outcomes and Quality of Life Improvement After Multilevel Spinal Fusion in Elderly Patients

STUDY DESIGN

Retrospective case series.

OBJECTIVES

Both the rate and complexity of spine surgeries in elderly patients has increased. This study reports the outcomes of multilevel spine fusion in elderly patients and provides evidence on the appropriateness of complex surgery in elderly patients.

METHODS

We identified 101 patients older than70 years who had ≥5 levels of fusion. Demographic, medical, and surgical data, and change between preoperative and >500 days postoperative health survey scores were collected. Health surveys were visual analogue scale (VAS), EuroQoL 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society questionnaire (SRS-30), and Short Form health survey (SF-12) (physical composite score [PCS] and mental composite score [MCS]). Minimal clinically important differences (MCIDs) were defined for each survey.

RESULTS

Complications included dural tears (19%), intensive care unit admission (48%), revision surgery within 2 to 5 years (24%), and death within 2 to 5 years (16%). The percentage of patients who reported an improvement in health-related quality of life (HRQOL) of at least an MCID was: VAS Back 69%; EQ-5D 41%; ODI 58%; SRS-30 45%; SF-12 PCS 44%; and SF-12 MCS 48%. Improvement after a primary surgery, as compared with a revision, was on average 13 points higher in ODI (P = .007). Patients who developed a surgical complication averaged an improvement 11 points lower on ODI (P = .042). Patients were more likely to find improvement in their health if they had a lower American Society of Anesthesiologists or Charlson Comorbidity Index score or a higher metabolic equivalent score.

CONCLUSIONS

In multilevel surgery in patients older than 70 years, complications are common, and on average 77% of patients attain some improvement, with 51% reaching an MCID. Physiological status is a stronger predictor of outcomes than chronological age.

Wide Variability in Patient-Reported Outcomes Measures After Fusion for Lumbar Spinal Stenosis: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The purpose of this study is to review outcomes reporting methodology in studies evaluating fusion for lumbar spinal stenosis.

METHODS

A systematic review of PubMed and Embase databases was conducted from January 2007 to June 2017 for English language studies with minimum of 2 years postoperative follow-up reporting outcomes after fusion for lumbar spinal stenosis. Two reviewers assessed each study; those meeting inclusion criteria were examined for pertinent data. Outcome measures were categorized into relevant domains: pain/symptomatology, function/disability, and surgical satisfaction. Return to work reporting was also recorded.

RESULTS

Of 123 studies meeting inclusion criteria, 76% included posterior-only fusion, 32% included posterior/transforaminal interbody fusion, and 5% included anterior/lateral interbody fusion (non-mutually exclusive). There was significant variation in patient-reported outcomes (PROs) used-studies reported 31 unique PROs assessing at least one domain: 22 evaluating pain, 23 evaluating function, and 3 evaluating surgical satisfaction. Most commonly utilized PROs were the Oswestry Disability Index (73% of studies), Visual Analog Scale (55%), and 36-Item Short Form Survey (32%). The remaining 28 measures were used in 14% of studies or fewer. PROs specific to symptoms of lumbar spinal stenosis, such as the Zurich Claudication Questionnaire, were only used rarely (7/123 studies). Only 14% of studies reported on time to return to work.

CONCLUSIONS

The literature surrounding fusion in the setting of lumbar stenosis is characterized by substantial variability in outcomes reporting. Very few studies utilized measures specific to lumbar spinal stenosis. Efforts to standardize outcomes reporting would facilitate comparisons of surgical interventions.

Decompression With or Without Fusion for Lumbar Stenosis: A Cost Minimization Analysis

STUDY DESIGN

Retrospective database review.

OBJECTIVE

Compare 1-year episode of care costs between single-level decompression and decompression plus fusion for lumbar stenosis.

SUMMARY OF BACKGROUND DATA

Lumbar stenosis is the most common indication for surgery in patients over 65. Medicare direct hospital costs for lumbar surgery reached $1.65 billion in 2007. Despite stenosis being a common indication for surgery, there is debate as to the preferred surgical treatment. Cost-minimization analysis is a framework that identifies potential cost savings between treatment options that have similar outcomes. We performed a cost-minimization analysis of decompression versus decompression with fusion for lumbar stenosis from the payer perspective.

METHODS

An administrative claims database of privately insured patients (Humana) identified patients who underwent decompression (n = 5349) or decompression with fusion (n = 8540) for lumbar stenosis with and without spondylolisthesis and compared overall costs. All patients were identified and costs identified for a 1-year period. Complication rates and costs were described using summary statistics.

RESULTS

Mean treatment costs at 1 year after surgery were higher for patients who underwent decompression and fusion compared to patients who underwent decompression alone ($20,892 for fusion vs. $6329 for decompression; P < 0.001). Facility costs (P < 0.001), surgeon costs (P < 0.001), and physical therapy costs (P < 0.001) were higher in the fusion group. Cost differences related to infection or durotomy reached significance (P < 0.04). No difference in cost was identified for supplies.

CONCLUSION

Decompression had significantly lower costs for the treatment of lumbar stenosis, including treatment for postoperative complications. If cost minimization is the primary goal, decompression is favored for surgical treatment of lumbar stenosis. Other factors including shared decision-making directed toward patient's values, patient-reported outcomes, and preferences should also be recognized as drivers of healthcare decisions.

LEVEL OF EVIDENCE

3.

American Society of Anesthesiologists' Status Association With Cost and Length of Stay in Lumbar Laminectomy and Fusion: Results From an Institutional Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF).

SUMMARY OF BACKGROUND DATA

Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF.

METHODS

This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS.

RESULTS

A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001).

CONCLUSION

ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives.

LEVEL OF EVIDENCE

3.

Costs Associated with the Treatment of Low Back Disorders: A Comparison of Surgeons and Physiatrists

BACKGROUND

Spine care is costly and subject to wide variability. Defining costs and patterns of care for different specialties is critical to improving value.

OBJECTIVE

Determine costs, utilization, and differences therein for nonoperative and operative specialists in treating low back disorders. We hypothesized costs associated with nonoperative specialists would be lower.

DESIGN

Retrospective cohort.

SETTING

Medicare Limited Data Set (5% sample), 2011 to 2014.

PARTICIPANTS

A total of 170 011 patients saw a primary care provider for a low back disorder between 1 July 2011, and 1 January 2013. Excluding those seen for a low back disorder in the preceding 6 months, final cohorts totaled 11 829 patients subsequently evaluated by a physiatrist (specialist in physical medicine and rehabilitation; 3183 patients) or surgeon (orthopedic or neurosurgeon; 8646 patients) within the following 6 months.

MAIN OUTCOME MEASURES

Total Medicare expenditures, spine-specific costs, spine surgical rates over 24 months.

RESULTS

Cohorts had comparable demographics, initial diagnoses, and baseline mean per-member per-month (PMPM) total spending. Mean 2-year spine-specific spending was $3978 for the physiatrist cohort and $7387 for the surgeon cohort. Comparatively, the physiatrist cohort had lower total mean 2-year spine-specific spending (-$3409; 95% confidence interval [CI] -$3824 to -$2994), mean PMPM total spending (-$122/mo; CI -$184 to -$60), and surgical rate (7.8% vs. 18.9%, risk ratio [RR] = 0.41; CI 0.36-0.47). Surgery predominantly drove cost differential. Mean PMPM total spending for both cohorts remained elevated at 24 months compared to baseline mean spending (physiatrist: +$293; CI $447 to $138; surgeon: +$325; CI $425 to $225).

CONCLUSIONS

Following a new episode of a low back disorder, substantial costs were seen for those subsequently evaluated by a physiatrist or surgeon. Costs were considerably lower for those first seen by a physiatrist. Patients in both cohorts displayed long-term increases in health care costs. Our data suggest that early engagement in nonoperative care, when appropriate, may improve value.

National Trends in the Surgical Management of Lumbar Spinal Stenosis in Adult Spinal Deformity Patients

STUDY DESIGN

This is a retrospective analysis of national administrative hospital data.

OBJECTIVE

This study examines national trends in the surgical management of lumbar spinal stenosis (LSS) in patients with and without coexisting scoliosis between 2010 and 2014. The study also examines revision rates for LSS procedures.

SUMMARY OF BACKGROUND DATA

There is wide variability in the surgical management of patients with LSS, with and without coexisting spinal deformity.

METHODS

Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample Database. International Classification of Diseases 9th revision- Clinical Modification codes were used to identify all patients with a primary diagnosis of lumbar spinal stenosis. These patients were divided into two groups: 1) LSS alone and 2) LSS with coexisting scoliosis. The two groups were examined for one of three surgical outcomes: 1) decompression alone (discectomy, laminectomy), 2) simple fusion, and 3) complex fusion (>three vertebrae or 360° fusion). The groups were then further examined for revision operations. National Inpatient Sample discharge weights were applied where relevant.

RESULTS

In 2014 national estimates of discharged patients indicated 76,275 patients with a primary diagnosis of LSS (population rate, 23.9; in the elderly (65+) the age-adjusted population rate was 95.4). Of these patients, 88.5% were managed through primary surgery (34.6% decompression, 47.2% simple fusion, 5.7% complex fusion). Between 2010 and 2014, the percentage of decompression decreased from 47.5% to 34.6%, the percent of simple fusion increased from 35.3% to 47.2%, and the percent of complex fusion increased from 5.7% to 7.1% (P < 0.01). In patients with coexisting scoliosis, lumbar spinal stenosis was predominantly managed by simple fusion and complex fusion (15.5% decompression, 51.9% simple fusion, 27.3% complex fusion, in 2014). Revision rates were highest among patients without scoliosis managed with complex fusion (15.8% in 2014) compared with patients with scoliosis (8.8% in 2014). Patients with scoliosis who underwent decompression only had revision rates of 1.7% and 0.62% in 2010 and 2014, respectively.

CONCLUSION

We observed a leveling-off of the rate of operation for patients with a primary diagnosis of LSS at around 88%. There was an increase in the rate of fusion and a decrease in the rate of decompression across all patient groups. We report no difference in revision rates between patients with and without scoliosis, except in those undergoing a complex fusion.

LEVEL OF EVIDENCE

3.

The problems associated with revision surgery

This article highlights the issue related to revision surgery in spine and the possible implications in the next future. These slides can be retrieved under Electronic Supplementary Material.