Treatment of Degenerative Lumbar Spondylolisthesis With Fusion or Decompression Alone Results in Similar Rates of Reoperation at 5 Years

Decompression alone or fusion in single-level lumbar spinal stenosis with spondylolisthesis? A systematic review and meta analysis

PURPOSE

The objective of this systematic review and metaanalysis is to compare the efficacy and safety of decompression alone versus decompression plus fusion in single-level lumbar spinal stenosis with spondylolisthesis.

METHODS

A comprehensive search of the PubMed, Embase, Cochrane Library, and Ovid Medline databases was conducted to find randomized control trials (RCTs) or cohort studies that compared decompression alone and decompression plus fusion in single-level lumbar spinal stenosis with spondylolisthesis. Operation time; reoperation; postoperative complications; postoperative Oswestry disability index(ODI) scores and scores related to back and leg pain were collected from eligible studies for meta-analysis.

RESULTS

We included 3 randomized controlled trials and 9 cohort studies with 6182 patients. The decompression alone group showed less operative time(P < 0.001) and intraoperative blood loss(p = 0.000), and no significant difference in postoperative complications was observed in randomized controlled trials(p = 0.428) or cohort studies(p = 0.731). There was no significant difference between the other two groups in reoperation(P = 0.071), postoperative ODI scores and scores related to back and leg pain.

CONCLUSIONS

In this study, we found that the decompression alone group performed better in terms of operation time and intraoperative blood loss, and there was no significant difference between the two surgical methods in rate of reoperation and postoperative complications, ODI, low back pain and leg pain. Therefore, we come to the conclusion that decompression alone is not inferior to decompression and fusion in patients with single-level lumbar spinal stenosis with spondylolisthesis.

A systematic review and meta-analysis of risk factors for reoperation after degenerative lumbar spondylolisthesis surgery

BACKGROUND

Considering the high reoperation rate in degenerative lumbar spondylolisthesis (DLS) patients undergoing lumbar surgeries and controversial results on the risk factors for the reoperation, we performed a systematic review and meta-analysis to explore the reoperation rate and risk factors for the reoperation in DLS patients undergoing lumbar surgeries.

METHODS

Literature search was conducted from inception to October 28, 2022 in Pubmed, Embase, Cochrane Library, and Web of Science. Odds ratio (OR) was used as the effect index for the categorical data, and effect size was expressed as 95% confidence interval (CI). Heterogeneity test was performed for each outcome effect size, and subgroup analysis was performed based on study design, patients, surgery types, follow-up time, and quality of studies to explore the source of heterogeneity. Results of all outcomes were examined by sensitivity analysis. Publication bias was assessed using Begg test, and adjusted using trim-and-fill analysis.

RESULTS

A total of 39 cohort studies (27 retrospective cohort studies and 12 prospective cohort studies) were finally included in this systematic review and meta-analysis. The overall results showed a 10% (95%CI: 8%-12%) of reoperation rate in DLS patients undergoing lumbar surgeries. In surgery types subgroup, the reoperation rate was 11% (95%CI: 9%-13%) for decompression, 10% (95%CI: 7%-12%) for fusion, and 9% (95%CI: 5%-13%) for decompression and fusion. An increased risk of reoperation was found in patients with obesity (OR = 1.91, 95%CI: 1.04-3.51), diabetes (OR = 2.01, 95%CI: 1.43-2.82), and smoking (OR = 1.51, 95%CI: 1.23-1.84).

CONCLUSIONS

We found a 10% of reoperation rate in DLS patients after lumbar surgeries. Obesity, diabetes, and smoking were risk factors for the reoperation.

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

STUDY DESIGN

Systematic review and Meta-analysis.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of 270-degree percutaneous transforaminal endoscopic decompression under local anesthesia and minimally invasive transforaminal lumbar interbody fusion in the treatment of geriatric lateral recess stenosis associated with degenerative lumbar spondylolisthesis

PURPOSE

Various lumbar decompression techniques have been used for the treatment of degenerative lumbar spondylolisthesis (DLS). Few studies have compared the clinical efficacy of percutaneous transforaminal endoscopic decompression (PTED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lateral recess stenosis associated with DLS (LRS-DLS) in geriatric patients. The objective of the study was to compare the safety and short-term clinical efficacy of 270-degree PTED under local anesthesia and MIS-TLIF in the treatment of LRS-DLS in Chinese geriatric patients over 60 years old.

MATERIALS AND METHODS

From January 2017 to August 2019, the data of 90 consecutive geriatric patients with single-level L4-5 LRS-DLS were retrospectively reviewed, including those in the PTED group (n = 44) and MIS-TLIF group (n = 46). The patients were followed up for at least 1 year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. X-ray examinations were performed 1 year after surgery to assess the progression of spondylolisthesis in the PTED group and bone fusion in the MIS-TLIF group.

RESULTS

The mean patient ages in the PTED and MIS-TLIF groups were 70.3 years and 68.6 years, respectively. Both the PTED and MIS-TLIF groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time point (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the PTED group was similar to that in the MIS-TLIF group (90.9% vs. 91.3%, P > 0.05), PTED was advantageous in terms of the operative time, estimated blood loss, incision length, drainage time, drainage volume, length of hospital stay, and complications.

CONCLUSIONS

Both PTED and MIS-TLIF led to favorable outcomes in geriatric patients with LRS-DLS. In addition, PTED caused less severe trauma and fewer complications. In terms of perioperative quality-of-life and clinical outcomes, PTED could supplement MIS-TLIF in geriatric patients with LRS-DLS.

Surgical Treatment of Single-Level Lumbar Stenosis Is Associated with Lower 2-Year Mortality and Total Cost Compared with Nonsurgical Treatment: A Risk-Adjusted, Paired Analysis

BACKGROUND

Spine surgery has demonstrated cost-effectiveness in reducing pain and restoring function, but the impact of spine surgery relative to nonsurgical care on longer-term outcomes has been less well described. Our objective was to compare single-level surgical treatment for lumbar stenosis, with or without spondylolisthesis, and nonsurgical treatment with respect to patient mortality, resource utilization, and health-care payments over the first 2 years following initial treatment.

METHODS

A retrospective review of the Medicare National Database Fee for Service Files from 2011 to 2017 was performed. A 2-year prediction of mortality risk (risk stratification index, RSI) was used as a measure of patient baseline health. Patients (88%) were matched by RSI and demographics. Mortality, spine-related health-care utilization, and 2-year total Medicare payments for patients undergoing surgical treatment were compared with matched patients undergoing nonsurgical treatment.

RESULTS

We identified 61,534 patients with stenosis alone and 83,813 with stenosis and spondylolisthesis. Surgical treatment was associated with 28% lower 2-year mortality compared with matched patients undergoing nonsurgical treatment. Total Medicare payments were significantly lower for patients with stenosis alone undergoing laminectomy alone and for patients with stenosis and spondylolisthesis undergoing laminectomy with or without fusion compared with patients undergoing nonsurgical treatment. There was no significant difference in mortality when fusion or laminectomy was compared with combined fusion and laminectomy. However, laminectomy alone was associated with significantly lower 2-year payments when treating stenosis with or without spondylolisthesis.

CONCLUSIONS

Surgical treatment for stenosis with or without spondylolisthesis within the Medicare population was associated with significantly lower mortality and total medical payments at 2 years compared with nonsurgical treatment, although residual confounding could have contributed to these findings.

LEVEL OF EVIDENCE

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

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.

Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis

BACKGROUND

Clinically, there are substantive practice variations in surgical management of degenerative lumbar spondylolisthesis. We aimed at evaluating whether decompression alone outcomes for patients with degenerative lumbar spondylolisthesis are comparable to those of decompression with fusion.

METHODS

In this meta-analysis, the Embase, PubMed, and Cochrane Library databases were searched from inception to February 16th, 2022. Randomised controlled trials (RCTs) and cohort studies comparing decompression alone with decompression and fusion for patients with degenerative lumbar spondylolisthesis were included in this study. There were no language limitations. Odds ratio (OR), mean difference (MD) and 95% confidence interval (CI) were used to report results in the random-effects model. Main outcomes included Oswestry disability index (ODI), pain, clinical satisfaction, complication and reoperation rates. The study protocol was published in PROSPERO (CRD42022310645).

FINDINGS

Thirty-three studies (6 RCTs and 27 cohort studies) involving 94 953 participants were included. Differences in post-operative ODI between decompression alone and decompression with fusion were not significant. A small difference for back (MD, 0.13; [95% CI, 0.08 to 0.18]; I ²:0.00%) and leg pain (MD, 0.30; [95% CI, 0.09 to 0.51]; I ²:48.35%) was observed on the 3rd post-operative month. The results did not reveal significant differences in leg pain and back pain between decompression alone and fusion groups on the 6th, 12th, and 24th post-operative months. Difference in clinical satisfaction between decompression alone and decompression with fusion were not significant from RCTs (OR, 0.26; [95% CI, 0.03 to 1.92]; I ²:83.27%). Complications (OR, 1.54; [95% CI, 1.16 to 2.05]; I ²:48.88%), operation time (MD, 83.39; [95% CI, 55.93 to 110.85]; I ²:98.75%), intra-operative blood loss (MD, 264.58; [95% CI, 174.99 to 354.16]; I ²:95.61%) and length of hospital stay (MD, 2.85; [95% CI, 1.60 to 4.10]; I ²:99.49%) were higher with fusion.

INTERPRETATION

Clinical effectiveness of decompression alone was comparable to that of decompression with fusion for degenerative lumbar spondylolisthesis. Decompression alone is recommended for patients with degenerative lumbar spondylolisthesis.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (No. 81871818), Tangdu Hospital Seed Talent Program (Fei-Long Wei), Natural Science Basic Research Plan in Shaanxi Province of China (No.2019JM-265) and Social Talent Fund of Tangdu Hospital (No.2021SHRC034).

Decompression Alone Compared to Decompression With Fusion in Patients With Lumbar Spondylolisthesis: Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

We aimed to synthesize the latest evidence on the efficacy and safety of decompression alone compared to decompression with fusion in patients with lumbar spondylolisthesis. We also aimed to evaluate factors affecting the efficacy and complications.

METHODS

A systematic literature search was conducted using PubMed, Scopus, Europe PMC, Cochrane Central Database, and ClinicalTrials.gov. The main outcome was improvement in Oswestry Disability Index (ODI). The secondary outcome was back pain and leg pain improvement, complications, reoperation rate, duration of surgery, length of hospital stay, and blood loss.

RESULTS

There were 3993 patients from 13 studies. Decompression with fusion was associated with greater reduction in ODI (mean difference 4.04 [95% CI 0.95, 7.13], P = 0.01) compared to decompression alone. Greater reduction in back (standardized mean difference [SMD] 0.27 [95% CI 0.00, 0.53], P = 0.05) and leg pain (SMD 0.13 [95% CI 0.06, 0.21], P < 0.001) was observed in the decompression with fusion group. Complications were similar in the 2 groups (OR 0.60 [95% CI 0.34, 1.04], P = 0.07). The reoperation rate was similar in both groups (P = 0.54). Decompression alone resulted in shorter duration of surgery (mean difference -85.18 minutes [95% CI -122.79, -47.57], P < 0.001), less blood loss (mean difference -262.65 mL [95% CI -313.45, -211.85], P < 0.001), and shorter hospital stay (mean difference -2.64 days [95% CI -3.58, -1.70], P < 0.001). Empirical Bayes random-effects meta-regression showed that the rate of complication was influenced by age (coefficient 0.172, P = 0.004).

CONCLUSION

Decompression with fusion had greater efficacy than decompression alone but was associated with more blood loss, lengthier surgery, and hospitalization. In terms of complications, decompression alone may be beneficial in younger patients. (PROSPERO CRD42020211904) LEVEL OF EVIDENCE: 2A.

Frailty is an important predictor of 30-day morbidity in patients treated for lumbar spondylolisthesis using a posterior surgical approach

BACKGROUND CONTEXT

Traditionally, a nonoperative approach has been favored for elderly patients with lumbar spondylolisthesis due to a perceived higher risk of morbidity with surgery. However, most studies have used an arbitrary age cut-off to define "elderly" and this research has yielded conflicting results.

PURPOSE

The purpose of this study was to investigate the impact of frailty on morbidity after surgery for degenerative lumbar spondylolisthesis treated with a posterior approach.

STUDY DESIGN

A retrospective cohort study was performed.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, with years 2010 to 2018 included in this study. Patients who received posterior lumbar spine decompression with or without single level posterior instrumented fusion for degenerative lumbar spondylolisthesis were included. Patients who received anterior and/or lateral approaches were excluded.

OUTCOME MEASURES

The primary outcome was Clavien-Dindo grade IV complication. Secondary outcomes were readmission, reoperation, and discharge to location other than home.

METHODS

Patient demographics and comorbidities were extracted. Logistic regression analysis was performed to investigate the association between outcomes and the Modified Frailty Index-5, adjusting for age, gender, body mass index, smoking status, and surgical procedure performed. A sub-analysis was done to assess the effect of frailty in three different age groups (18-45 years, 46-65 years, and >65 years) for the two surgical cohorts.

RESULTS

There were 15,658 patients in this study. The mean age was 62.5 years. Approximately 70% of the patients received decompression with fusion. Frailty was significantly associated with an increased risk of major complication, unplanned readmission, reoperation, and non-home discharge. The risk increased with increasing frailty. For patients who received decompression, frailty was associated with a higher risk of readmission and non-home discharge in patients >65 years. For patients who received decompression and fusion, frailty was associated with a higher risk of complications, readmission, and non-home discharge in patients >65 years.

CONCLUSIONS

Frailty is independently associated with a higher risk of morbidity after posterior surgery in patients with lumbar spondylolisthesis, especially in patients older than 65. These data are of significance to clinicians in planning treatment for these patients.

Risk Factors for Spine Reoperation and Joint Replacement Surgeries after Short-Segment Lumbar Spinal Surgeries for Lumbar Degenerative Disc Disease: A Population-Based Cohort Study

Background: Short-segment lumbar spinal surgery is the most performed procedure for treatment of degenerative disc disease. However, population-based data regarding reoperation and joint replacement surgeries after short-segment lumbar spinal surgery is limited. Methods: The study was a retrospective cohort design using the Taiwan National Health Insurance Research Database for data collection. Patients selected were diagnosed with lumbar degenerative disc disease and undergone lumbar discectomy surgery between 2002 and 2013. The Kaplan–Meier method was used to estimate the incidence of 1-year spine reoperation and joint replacement surgeries, and the Cox proportional hazard regression was used to examine risk factors associated with the outcomes of interest. Results: A total of 90,105 patients were included. Incidences of 1-year spine reoperation and joint replacement surgeries for the hip and knee were 0.27, 0.04, and 0.04 per 100 people/month. Compared to fusion with the fixation group, fusion without fixation and the non-fusion group had higher risks of spine reoperation. Risk factors associated with spine reoperation included fusion without fixation, non-fusion surgery, age ≥ 45 years old, male gender, diabetes, a Charlson Comorbidity Index = 0, lowest social economic status, and steroid use history. Spine surgeries were not risk factors for joint replacement surgeries. Conclusions: Non-fusion surgery and spinal fusion without fixation had higher risks for spine reoperation. Spine surgeries did not increase the risk for joint replacement surgeries.

Clinical Outcomes of Minimally Invasive Posterior Decompression for Lumbar Spinal Stenosis with Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare the clinical outcomes 5 years after minimally invasive posterior decompression for lumber spinal stenosis (LSS) between patients with and without degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA

Indications for surgical procedures for patients with LSS and DS are still under investigation. Since minimally invasive surgery does not affect most anatomical structures, preoperative DS may not negatively affect the clinical outcomes of minimally invasive posterior decompression.

METHODS

Overall, 198 patients with LSS who underwent microendoscopic or microscopic decompression and were followed up for more than 5 years postoperatively were included in the present study. Patients who showed a segmental kyphosis >5° at the surgical level during flexion were treated with fusion surgery. However, other patients, including those with DS, were treated with posterior decompression. The patients were divided into two groups: the DS group included 82 patients with >3-mm slip and the non-DS group included 112 patients with ≤3-mm slip or without slip. A mixed-effects model adjusted for age and sex was used to compare the improvements in the visual analog scale score for low-back pain and the Japanese Orthopaedic Association score of the two groups. For subgroup analysis (n = 53), the changes in the preoperative physical component summary and the mental component summary of Short Form-36 of the two groups at 5 years after surgery were evaluated.

RESULTS

There was no significant difference in the improvement of preoperative low-back pain visual analog scale score and Japanese Orthopaedic Association score 5 years after surgery between the two groups. Subgroup analysis showed no significant difference between the two groups in the improvement of preoperative physical component summary and mental component summary 5 years after surgery.

CONCLUSION

After carefully eliminating patients with segmental instability, DS did not affect the clinical outcomes of minimally invasive decompression surgery.Level of Evidence: 3.

In-hospital Course and Complications of Laminectomy Alone Versus Laminectomy Plus Instrumented Posterolateral Fusion for Lumbar Degenerative Spondylolisthesis: A Retrospective Analysis of 1804 Patients from the NSQIP Database

STUDY DESIGN

Retrospective analysis of data from the National Surgical Quality Improvement Program (NSQIP).

OBJECTIVE

We sought to compare the short-term outcomes of laminectomy with/without fusion for single-level lumbar degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA

Lumbar DS is a common cause of low back and radicular pain. Controversy remains over the safety and efficacy of fusion in addition to standard decompressive surgery.

METHODS

Patients with lumbar DS who underwent laminectomy alone or laminectomy plus posterolateral fusion at a single level were identified from the 2012-2017 NSQIP database. Outcomes included 30-day mortality, major complication, reoperation, readmission, as well as operative duration, need for blood transfusion, length of stay (LOS), and discharge destination. Outcomes were compared between treatment groups by multivariable regression, adjusting for age, sex, and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD).

RESULTS

The study cohort consisted of 1804 patients; of these, 802 underwent laminectomy alone and 1002 laminectomy plus fusion. On both unadjusted and adjusted analyses, there was no difference in 30-day mortality, major complications, reoperation, or readmission. However, laminectomy plus fusion was associated with longer operative time (170.0 vs. 152.7 minutes; aMD 16.00 minutes, P < 0.001), longer hospital LOS (3.2 vs. 2.5 days; aMD 0.68, P < 0.001), more frequent need for intra- or postoperative blood transfusion (6.8% vs. 3.1%; aOR 2.24, P = 0.001), and less frequent discharge home (80.7% vs. 89.2%; aOR 0.46, P < 0.001).

CONCLUSION

We found single-level laminectomy plus fusion for lumbar DS to have a comparable short-term safety profile to laminectomy alone. However, fusion was associated with longer operative time and LOS, higher risk of blood transfusion, and greater need for inpatient rehabilitation. These factors should be recognized by clinicians and discussed with patients in the context of their values when weighing surgical treatment of lumbar DS.Level of Evidence: 3.

Degenerative Spondylolisthesis: When to Fuse and When Not to? A New Scoring System

STUDY DESIGN

A prospective cohort.

OBJECTIVE

The objective of this study was to develop a scoring system for lumbar degenerative spondylolisthesis (LDS) that would guide decision-making.

BACKGROUND

The management protocol for LDS has been under debate, with no guidelines. Most studies oversimplify LDS as a homogenous entity.

MATERIALS AND METHODS

A retrospective analysis of 131 patients who underwent surgery for LDS between July 2007 and October 2011 with a minimum follow-up of 3 years was carried out on the basis of clinical, radiologic, and technical factors. A scoring system was conceptualized. Clinical: back pain score-2, age younger than 70 years-1, high-demand activity-1. Radiologic: segmental kyphosis-1.5, segmental dynamic translation-1, disk height >50% of adjacent level-1, facet effusion-1, sagittal facet-orientation-1. Technical: feasibility to decompress without causing instability-1.5. Its reliability was ascertained by a univariate analysis. The benchmark was set at 5.5 according to the Youden Index. This was followed by a prospective study for reliability analysis between November 2011 and January 2017 of 52 patients who underwent stand-alone decompression in LDS with a minimum follow-up of 24 months. Outcomes were evaluated using the Oswestry Disability Index and the Visual Analog Scale. Interobserver variability was determined. None of the patients in the retrospective or prospective group had undergone any lumbar surgery previously.

RESULTS

The mean Oswestry Disability Index and Visual Analog Scale of both the groups in the retrospective and the stand-alone decompression groups in prospective studies showed significant improvement. The interobserver reliability was high, with a κ value of 0.847.

CONCLUSIONS

The proposed scoring system helps view LDS as a heterogenous condition and assists in tailoring treatment for individual patients. For a select subgroup of patients with LDS, minimally invasive decompression (unilateral laminotomy and bilateral decompression using a minimally invasive surgery tubular retractor system) without fusion is adequate.

LEVEL OF EVIDENCE

Level III.

Percutaneous Transforaminal Endoscopic Decompression for Geriatric Patients with Central Spinal Stenosis and Degenerative Lumbar Spondylolisthesis: A Novel Surgical Technique and Clinical Outcomes

Purpose

Percutaneous transforaminal endoscopic decompression (PTED) is an ultra-minimally invasive surgical option for patients that does not involve the same amount of destabilizing facet joint removal as a traditional laminectomy. The objective of this study was to describe the procedure of PTED under local anesthesia for geriatric patients with central spinal stenosis and degenerative lumbar spondylolisthesis (CSS-DLS).

Materials and Methods

From January 2016 to December 2018, 30 consecutive geriatric patients who underwent surgery for single-level CSS-DLS were retrospectively reviewed. All patients were followed for at least 12 months (12–24 months). The visual analog scale (VAS) scores, Oswestry disability index (ODI) scores and modified MacNab criteria were used to evaluate the clinical results.

Results

The mean age was 73.1±6.0 years. Follow-up ranged from 12 to 36 months. The mean±SD values of the preoperative VAS for leg pain and ODI were 7.4±1.0 and 67.2±8.4, respectively. The values improved to 2.2±1.1 and 19.9±8.1 at 12 months postoperatively. The outcomes of the modified MacNab criteria showed that 93.3% of patients obtained a good-to-excellent rate. The percent slippage of spondylolisthesis before surgery (13.8±2.5%) and at the end of follow-up (14.0±2.5%) was not significantly different.

Conclusion

PTED under local anesthesia could be a useful supplement to traditional decompression in geriatric patients with CSS-DLS.

Percutaneous transforaminal endoscopic decompression for lumbar spinal stenosis with degenerative spondylolisthesis in the elderly

OBJECTIVES

Percutaneous transforaminal endoscopic decompression (PTED) under local anesthesia is rarely performed for lumbar spinal stenosis (LSS) with degenerative lumbar spondylolisthesis (DLS) because of the limited field of vision, inherent instability, etc. The objective of this study was to describe the procedure of the PTED technique and to demonstrate the early clinical outcomes.

PATIENTS AND METHODS

From January 2017 to January 2019, 40 consecutive patients aged 60 and older were diagnosed with LSS with DLS in our institution and underwent PTED. All patient were followed up to 1 year postoperatively. The clinical outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria.

RESULTS

The mean age was 70.2 ± 7.1 years. Follow-up ranged from 12 to 24 months. The mean ± SD values of the preoperative VAS leg pain and ODI scores were 7.5 ± 1.1 and 67.3 ± 9.3, respectively. The scores improved to 2.2 ± 1.1 and 20.7 ± 8.1 at 12 months postoperatively. The outcomes of the modified MacNab criteria showed that 87.5 % of patients obtained a good-to-excellent rate. The percent slippage of spondylolisthesis before surgery (10.8 ± 2.6 %) and at the end of follow-up (11.0 ± 2.4 %) was not significantly different. One patient had a dural tear and intracranial hypertension, and one patient had tibialis anterior weakness.

CONCLUSION

PTED under local anesthesia could be an effective treatment method for LSS with DLS in elderly patients. However, potential complications still require further evaluation.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

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.

Leveraging Digital Data to Inform and Improve Quality Cancer Care

BACKGROUND

Efficient capture of routine clinical care and patient outcomes is needed at a population-level, as is evidence on important treatment-related side effects and their effect on well-being and clinical outcomes. The increasing availability of electronic health records (EHR) offers new opportunities to generate population-level patient-centered evidence on oncologic care that can better guide treatment decisions and patient-valued care.

METHODS

This study includes patients seeking care at an academic medical center, 2008 to 2018. Digital data sources are combined to address missingness, inaccuracy, and noise common to EHR data. Clinical concepts were identified and extracted from EHR unstructured data using natural language processing (NLP) and machine/deep learning techniques. All models are trained, tested, and validated on independent data samples using standard metrics.

RESULTS

We provide use cases for using EHR data to assess guideline adherence and quality measurements among patients with cancer. Pretreatment assessment was evaluated by guideline adherence and quality metrics for cancer staging metrics. Our studies in perioperative quality focused on medications administered and guideline adherence. Patient outcomes included treatment-related side effects and patient-reported outcomes.

CONCLUSIONS

Advanced technologies applied to EHRs present opportunities to advance population-level quality assessment, to learn from routinely collected clinical data for personalized treatment guidelines, and to augment epidemiologic and population health studies. The effective use of digital data can inform patient-valued care, quality initiatives, and policy guidelines.

IMPACT

A comprehensive set of health data analyzed with advanced technologies results in a unique resource that facilitates wide-ranging, innovative, and impactful research on prostate cancer. This work demonstrates new ways to use the EHRs and technology to advance epidemiologic studies and benefit oncologic care.See all articles in this CEBP Focus section, "Modernizing Population Science."

In Degenerative Spondylolisthesis, Unilateral Laminotomy for Bilateral Decompression Leads to Less Reoperations at 5 Years When Compared to Posterior Decompression With Instrumented Fusion: A Propensity-matched Retrospective Analysis

STUDY DESIGN

Multicenter retrospective cohort study.

OBJECTIVE

The aim of this study was to compare reoperation rates at 5-year follow-up of unilateral laminotomy for bilateral decompression (ULBD) versus posterior decompression with instrumented fusion (Fusion) for patients with low-grade degenerative spondylolisthesis (DS) with lumbar spinal stenosis (LSS) in a multicenter database.

SUMMARY OF BACKGROUND DATA

Controversy exists regarding whether fusion should be used to augment decompression surgery in patients with LSS with DS. For years, the standard has been fusion with standard laminectomy to prevent postoperative instability. However, this strategy is not supported by Level 1 evidence. Instability and reoperations may be reduced or prevented using less invasive decompression techniques.

METHODS

We identified 164 patients with DS and LSS who underwent ULBD between January 2007 and December 2011 in a multicenter database. These patients were propensity score-matched on age, sex, race, and smoking status with patients who underwent Fusion (n = 437). Each patient required a minimum of 5-year follow-up. The primary outcome was 5-year reoperation. Secondary outcome measures included postoperative complication rates, blood loss during surgery, and length of stay. Logistic regression models were used to estimate the odds ratio of the 5-year reoperation rate between the two surgical groups.

RESULTS

The reoperation rate at 5-year follow-up was 10.4% in the ULBD group and 17.2% in the Fusion group. ULBD reoperations were more frequent at the index surgical level; Fusion reoperations were more common at an adjacent level. The two types of operations had similar postoperative complication rates, and both groups tended to have fusion reoperations.

CONCLUSION

For patients with stable DS and LSS, ULBD is a viable, durable option compared to fusion with decreased blood loss and length stay, as well as a lower reoperation rate at 5-year follow-up. Further prospective studies are required to determine the optimal clinical scenario for ULBD in the setting of DS.

LEVEL OF EVIDENCE

3.

Lumbar spondylolisthesis: modern registries and the development of artificial intelligence

OBJECTIVEThere are a wide variety of comparative treatment options in neurosurgery that do not lend themselves to traditional randomized controlled trials. The object of this article was to examine how clinical registries might be used to generate new evidence to support a particular treatment option when comparable options exist. Lumbar spondylolisthesis is used as an example.METHODSThe authors reviewed the literature examining the comparative effectiveness of decompression alone versus decompression with fusion for lumbar stenosis with degenerative spondylolisthesis. Modern data acquisition for the creation of registries was also reviewed with an eye toward how artificial intelligence for the treatment of lumbar spondylolisthesis might be explored.RESULTSCurrent randomized controlled trials differ on the importance of adding fusion when performing decompression for lumbar spondylolisthesis. Standardized approaches to extracting data from the electronic medical record as well as the ability to capture radiographic imaging and incorporate patient-reported outcomes (PROs) will ultimately lead to the development of modern, structured, data-filled registries that will lay the foundation for machine learning.CONCLUSIONSThere is a growing realization that patient experience, satisfaction, and outcomes are essential to improving the overall quality of spine care. There is a need to use practical, validated PRO tools in the quest to optimize outcomes within spine care. Registries will be designed to contain robust clinical data in which predictive analytics can be generated to develop and guide data-driven personalized spine care.

Noninstrumented Lumbar Fusion with Bone Morphogenetic Proteins for Spinal Stenosis with Spondylolisthesis in the Elderly

OBJECTIVE

This study examined the use of noninstrumented posterolateral lumbar fusion with bone morphogenetic protein (BMP) and compared its effectiveness with that of instrumented fusion for the treatment of lumbar spinal stenosis (LSS) with spondylolisthesis in elderly patients.

METHODS

This study was a retrospective review of 93 patients treated in a single-surgeon neurosurgical private practice over a 15-year period. Fifty-nine patients over the age of 65 who underwent noninstrumented posterolateral fusion with rhBMP-2 (Infuse) for LSS with spondylolisthesis were compared with 34 patients who underwent instrumented fusion without rhBMP-2. Outcomes in terms of reoperation rate, pain improvement, Oswestry Disability Index (ODI) score, and number of extra follow-up visits due to persistent problems were characterized by the use of t tests and χ² tests.

RESULTS

The reoperation rate in the noninstrumented rhBMP-2 fusion group was significantly lower than in the instrumented fusion group (17.6% vs. 3.4%, P = 0.048). The mean pain improvement was significantly higher in the noninstrumented rhBMP-2 group at 3 months (8.1 vs. 6.0, P < 0.001, 95% confidence interval [CI] 1.2 to 3.0) and at 1 year (7.25 vs. 5.6, P = 0.030, 95% CI 0.3 to 3.1). The ODI score improvement was significantly higher in the noninstrumented rhBMP-2 group (51 vs. 42.8, P < 0.001, 95% CI 4.7 to 11.6). The mean number of additional follow-up visits per patient was significantly lower in the noninstrumented rhBMP-2 group (0.068 vs. 1.23, P < 0.001, 95% CI 0.59 to 1.75).

CONCLUSION

Noninstrumented posterolateral lumbar fusion with rhBMP-2 in elderly patients with LSS and spondylolisthesis is a viable alternative to instrumented fusion based on clinical outcomes measured in this study.

Increased Proportion of Fusion Surgery for Degenerative Lumbar Spondylolisthesis and Changes in Reoperation Rate: A Nationwide Cohort Study With a Minimum 5-Year Follow-up

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objectives of the present study were to examine the changes in the number of surgeries, surgical methods selected, and reoperation rates between the years 2003 and 2008.

SUMMARY OF BACKGROUND DATA

The selection of the appropriate surgical method between decompression-only (D) and decompression plus fusion (DF) represents a challenging clinical dilemma in patients with degenerative lumbar spinal spondylolisthesis. DF is selected in greater than 90% of patients, mostly due to the associated low reoperation rate. However, the outcomes of D have been improved with minimally invasive decompression surgery techniques.

METHODS

The Health Insurance Review and Assessment Service database was used to create cohorts of all Korean patients who underwent surgery for degenerative lumbar spinal spondylolisthesis in 2003 (2003 cohort, n = 5624) and 2008 (2008 cohort, n = 11,706). All patients were followed up for at least 5 years. Reoperation was defined as the occurrence of any type of second lumbar surgery during the follow-up period. The probabilities of reoperation were calculated using the Kaplan-Meier method.

RESULTS

The number of surgeries increased 2.08-fold in 2008. Patients older than 60 years comprised 38.6% of the 2003 cohort and 52.4% of the 2008 cohort. The proportion of DF surgery was 31.13% in the 2003 cohort but 91.54% in the 2008 cohort. However, the high proportion of fusion surgery failed to reduce the reoperation probability in the 2008 cohort (8.1%) compared with that in the 2003 cohort (6.2%). The cost of DF was US$5264 and that of D was $2719 in 2008. DF decreased the reoperation probability by 1% at the cost of $421/patient in the 2008 cohort.

CONCLUSION

The increased proportion of fusion surgery without improvement in reoperation probability in an aging society may be cautiously addressed in deciding future health policies.

LEVEL OF EVIDENCE

4.

Microendoscopic Decompression for Lumbar Spinal Stenosis With Degenerative Spondylolisthesis: The Influence of Spondylolisthesis Stage (Disc Height and Static and Dynamic Translation) on Clinical Outcomes

STUDY DESIGN

This study was a retrospective subgroup analysis of prospective cohort data.

OBJECTIVE

The main objectives of this study were to develop a classification of degenerative spondylolisthesis (DS) and concurrent lumbar spinal stenosis (LSS) based on pathologic stage, and to determine how these subtypes of DS affect outcomes for minimally invasive (MIS) decompression SUMMARY OF BACKGROUND DATA:: DS with LSS is a common clinical scenario, yet there is no consensus on optimal treatment. Natural history of DS is described as early degenerative damage, followed by instability, and eventual restabilization via spondylotic changes. MIS decompression surgery has become increasingly popular, but the effect of DS subtypes on clinical outcomes after MIS decompression is unknown.

PATIENTS AND METHODS

From 2008 to 2013, all patients who underwent microendoscopic laminotomy for single-level LSS with DS were included. In total, 218 patients (91 male, 127 female individuals) were reviewed. DS pathologic staging was defined as early, advanced, or end stage, based on percent slippage (10% slippage), degree of dynamic instability (3 mm), and disc height. The following variables were evaluated preoperatively and >2 years postoperatively and compared among groups: Japanese Orthopaedic Association (JOA) score, JOA recovery rate, and Visual Analog Scale low back pain.

RESULTS

In total, 173 patients were included in final analysis. Final follow-up period was 2.3 years. Average JOA recovery rate was 63.8%. There were no significant differences in JOA recovery and Visual Analog Scale among 3 DS stages (P>0.05). In total, 9.8% of patients required additional spine surgery, with 5% requiring subsequent fusion. All patients who required subsequent fusion were in the advanced stage DS group.

CONCLUSIONS

Microendoscopic decompression is an effective treatment for patients with DS and concurrent LSS, with only 5% of patients requiring subsequent fusion at over 2-year follow-up, and another 5% requiring revision or adjacent segment decompression. The advanced stage DS group, indicating a >10% anterolisthesis and/or >3 mm of dynamic instability, was more likely to require additional surgery.

Decompression Alone Versus Decompression and Fusion for Lumbar Degenerative Spondylolisthesis: A Meta-Analysis

OBJECTIVE

To compare the effectiveness and safety of decompression alone (D group) with decompression and fusion (DF group) for patients who were diagnosed with lumbar degenerative spondylolisthesis (LDS).

METHODS

Electronic databases were searched for relevant studies that compared decompression alone with decompression and fusion for LDS. Then, data extraction and quality assessment were conducted, and the extracted data were analyzed by using RevMan 5.3. We used the random effects model for studies that had heterogeneity between them, and for those without heterogeneity, the fixed model was used.

RESULTS

Four randomized controlled trials and 14 nonrandomized controlled studies involving 77,994 patients were included for this meta-analysis. Although the DF group was associated with a higher postoperative change score on a visual analog scale compared with the D group in terms of back (P = 0.02) and leg (P = 0.04), they failed to reach the minimum clinically important difference. Moreover, no significant differences were found in Oswestry Disability Index, European Quality of Life-5 Dimensions, Short-Form 36 physical and mental component summaries score, and patients' satisfaction (P > 0.05) between treatment groups. Complication rate and reoperation rate (P > 0.05) were similar in both groups. Data analysis also showed that the DF group was associated with longer operation time (P < 0.00001), more intraoperative blood loss (P < 0.00001), and longer length of hospital stay (P < 0.00001).

CONCLUSIONS

Among patients with LDS, decompression and fusion surgery did not yield better clinical outcomes than decompression alone surgery. Also, the complication rate and reoperation rate were comparable between treatment groups. However, patients who had undergone decompression alone had shorter operation time, less intraoperative blood loss, and shorter hospital stay.