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Yang MMH, Far R, Riva-Cambrin J, Sajobi TT, Casha S. Poor postoperative pain control is associated with poor long-term patient-reported outcomes after elective spine surgery: an observational cohort study. Spine J 2024:S1529-9430(24)00196-7. [PMID: 38685277 DOI: 10.1016/j.spinee.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/14/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT A significant proportion of patients experience poorly controlled surgical pain and fail to achieve satisfactory clinical improvement after spine surgery. However, a direct association between these variables has not been previously demonstrated. PURPOSE To investigate the association between poor postoperative pain control and patient-reported outcomes after spine surgery. STUDY DESIGN Ambispective cohort study. PATIENT SAMPLE Consecutive adult patients (≥18-years old) undergoing inpatient elective cervical or thoracolumbar spine surgery. OUTCOME MEASURE Poor surgical outcome was defined as failure to achieve a minimal clinically important difference (MCID) of 30% improvement on the Oswestry Disability Index or Neck Disability Index at follow-up (3-months, 1-year, and 2-years). METHODS Poor pain control was defined as a mean numeric rating scale score of >4 during the first 24-hours after surgery. Multivariable mixed-effects regression was used to investigate the relationship between poor pain control and changes in surgical outcomes while adjusting for known confounders. Secondarily, the Calgary Postoperative Pain After Spine Surgery (CAPPS) Score was investigated for its ability to predict poor surgical outcome. RESULTS Of 1294 patients, 47.8%, 37.3%, and 39.8% failed to achieve the MCID at 3-months, 1-year, and 2-years, respectively. The incidence of poor pain control was 56.9%. Multivariable analyses showed poor pain control after spine surgery was independently associated with failure to achieve the MCID (OR 2.35 [95% CI=1.59-3.46], p<.001) after adjusting for age (p=.18), female sex (p=.57), any nicotine products (p=.041), ASA physical status >2 (p<.001), ≥3 motion segment surgery (p=.008), revision surgery (p=.001), follow-up time (p<.001), and thoracolumbar surgery compared to cervical surgery (p=.004). The CAPPS score was also found to be independently predictive of poor surgical outcome. CONCLUSION Poor pain control in the first 24-hours after elective spine surgery was an independent risk factor for poor surgical outcome. Perioperative treatment strategies to improve postoperative pain control may lead to improved patient-reported surgical outcomes.
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Affiliation(s)
- Michael M H Yang
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, 1403 29 Street NW, Calgary, Alberta, T2N 2T9, Canada; Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada; O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada.
| | - Rena Far
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, 1403 29 Street NW, Calgary, Alberta, T2N 2T9, Canada
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, 1403 29 Street NW, Calgary, Alberta, T2N 2T9, Canada; Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Steven Casha
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, 1403 29 Street NW, Calgary, Alberta, T2N 2T9, Canada; Hotchkiss Brain Institute, University of Calgary, 3300 Hospital Drive, Calgary, Alberta, T2N 4N1, Canada
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Zarei J, Mohammadi A, Akrami MR, Jeihooni Kalhori A. Designing a minimum data set for the information management system (registry) of spinal canal stenosis: An applied-descriptive study. Health Sci Rep 2023; 6:e1671. [PMID: 37920660 PMCID: PMC10618433 DOI: 10.1002/hsr2.1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
Background and Aims Spinal canal stenosis is one of the most common vertebral column diseases, which can lead to disability. Developing a registry system can help in research on the prevention and effective treatment of it. This study designs a minimum data set (MDS) as the first step in creating a registry system for spinal canal stenosis. Method The present research is of applied-descriptive type, performed in 2022. First, the applicable data elements about the disease were selected from a vast range of English and Farsi references, including peer reviewed articles, academic books, credible websites, and medical records of hospitalized patients. Through the extracted data, the primary MDS plan was designed as a questionnaire. The validity of the questionnaire was conducted via asking the opinion of experts (neurosurgeons, physiotherapists, epidemiologists, and health information management specialists). Also, its reliability was calculated via Cronbach ⍺ coefficient, which was 86%. Finally, the MDS of the spinal canal stenosis national registry system (for Iran) was confirmed through a two stage Delphi technique. Data analysis was applied through descriptive statistics via SPSS21 software. Results The proposed MDS is offered in two general sets of data: administrative and clinical. For the administrative data set, 40 data elements had been proposed, as five classes. Twenty-six of them were confirmed. In the clinical section, 95 data elements had been proposed in 14 classes; 94 of which were finally confirmed. Conclusion Since there is no spinal canal stenosis MDS available, this study can be a turning point in the standardization of the data on this disease. Moreover, these precise, coherent, and standard data elements can be contributed to improving disease management and enhancing the public healthcare quality. Also, the MDS proposed in this study can help researchers and experts, design a spinal canal stenosis registry system in other countries.
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Affiliation(s)
- Javad Zarei
- Department of Health Information Technology, School of Allied Medical SciencesAhvaz Jundishapur University of Medical SciencesAhvazIran
| | - Ali Mohammadi
- Department of Health Information Technology, School of Allied Medical SciencesKermanshah University of Medical ScienceKermanshahIran
| | - Mohamad Reza Akrami
- Department of Neurosurgery, School of MedicineKermanshah University of Medical SciencesKermanshahIran
| | - Azar Jeihooni Kalhori
- Department of Health Information Technology, School of Allied Medical SciencesAhvaz Jundishapur University of Medical SciencesAhvazIran
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Malik KN, Giberson C, Ballard M, Camp N, Chan J. Pain Management Interventions in Lumbar Spinal Stenosis: A Literature Review. Cureus 2023; 15:e44116. [PMID: 37753034 PMCID: PMC10518428 DOI: 10.7759/cureus.44116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Lumbar spinal stenosis (LSS) occurs due to the narrowing of the space within the vertebral canal and or intervertebral foramina. This results in the compression of the spinal cord and possibly the roots of the spinal nerves. Lower back pain and neurogenic claudication (NC) are major symptoms of spinal stenosis. This is a literature review that summarizes the important findings pertaining to pain management of spinal stenosis. Twenty-four original articles were assessed. Pain can be treated through non-invasive or surgical methods. Conservative techniques include physical exercises, epidural corticosteroid injection, local anesthetic injection therapy, and oral analgesics. Surgical intervention deals with the decompression of the affected spinal region, with or without vertebral fusion surgery. Other novel surgical techniques include implantation of specific equipment, known as interspinous spacer devices and minimally invasive lumbar decompression (MILD). Most studies offering a comparative analysis have demonstrated that surgical intervention is more efficacious than non-surgical interventions to manage pain associated with spinal stenosis.
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Affiliation(s)
- Kashif N Malik
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Curren Giberson
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Matthew Ballard
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Nathan Camp
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Justin Chan
- Physical Medicine and Rehabilitation, Western University of Health Sciences, Pomona, USA
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Sekiguchi M. The Essence of Clinical Practice Guidelines for Lumbar Spinal Stenosis, 2021: 5. Postoperative Prognosis. Spine Surg Relat Res 2023; 7:314-318. [PMID: 37636153 PMCID: PMC10447196 DOI: 10.22603/ssrr.2022-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/26/2022] [Indexed: 08/29/2023] Open
Affiliation(s)
- Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Kawakami M, Takeshita K, Inoue G, Sekiguchi M, Fujiwara Y, Hoshino M, Kaito T, Kawaguchi Y, Minetama M, Orita S, Takahata M, Tsuchiya K, Tsuji T, Yamada H, Watanabe K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication. J Orthop Sci 2023; 28:46-91. [PMID: 35597732 DOI: 10.1016/j.jos.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine. METHODS The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members. RESULTS Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided. CONCLUSIONS The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
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Affiliation(s)
| | | | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | - Yasushi Fujiwara
- Department of Orthopaedic Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City General Hospital, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Japan
| | | | - Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University, Japan
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What is success of treatment? Expected outcome scores in cervical radiculopathy patients were much higher than the previously reported cut-off values for success. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2761-2768. [PMID: 35551484 DOI: 10.1007/s00586-022-07234-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/04/2022] [Accepted: 04/17/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Treatment success can be defined by asking a patient how they perceive their condition compared to prior to treatment, but it can also be defined by establishing success criteria in advance. We evaluated treatment outcome expectations in patients undergoing surgery or non-operative treatment for cervical radiculopathy. METHODS The first 100 consecutive patients from an ongoing randomized controlled trial (NCT03674619) comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy were included. Patient-reported outcome measures and expected outcome and improvement were obtained before treatment. We compared these with previously published cut-off values for success. Arm pain, neck pain and headache were measured by a numeric rating scale. Neck disability index (NDI) was used to record pain-related disability. We applied Wilcoxon signed-rank test to compare the expected outcome scores for the two treatments. RESULTS Patients reported mean NDI of 42.2 (95% CI 39.6-44.7) at baseline. The expected mean NDI one year after the treatment was 4 (95% CI 3.0-5.1). The expected mean reduction in NDI was 38.3 (95% CI 35.8-40.8). Calculated as a percentage change score, the patients expected a mean reduction of 91.2% (95% CI 89.2-93.2). Patient expectations were higher regarding surgical treatment for arm pain, neck pain and working ability, P < 0.001, but not for headache. CONCLUSIONS The expected improvement after treatment of cervical radiculopathy was much higher than the previously reported cut-off values for success. Patients with cervical radiculopathy had higher expectations to surgical treatment.
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Mjåset C, Zwart JA, Kolstad F, Solberg T, Grotle M. Clinical improvement after surgery for degenerative cervical myelopathy; A comparison of Patient-Reported Outcome Measures during 12-month follow-up. PLoS One 2022; 17:e0264954. [PMID: 35259164 PMCID: PMC8903279 DOI: 10.1371/journal.pone.0264954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/18/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECT Although many patients report clinical improvement after surgery due to degenerative cervical myelopathy, the aim of intervention is to stop progression of spinal cord dysfunction. We wanted to provide estimates and assess achievement rates of Minimal Clinically Important Difference (MCID) at 3- and 12-month follow-up for Neck Disability Index (NDI), Numeric Rating Scale for arm pain (NRS-AP) and neck pain (NRS-NP), Euro-Qol (EQ-5D-3L), and European Myelopathy Score (EMS). METHODS 614 degenerative cervical myelopathy patients undergoing surgery responded to Patient-Reported Outcome Measures (PROMs) prior to, 3 and 12 months after surgery. External criterion was the Global Perceived Effect Scale (1-7), defining MCID as "slightly better", "much better" and "completely recovered". MCID estimates with highest sensitivity and specificity were calculated by Receiver Operating Curves for change and percentage change scores in the whole sample and in anterior and posterior procedural groups. RESULTS The NDI and NRS-NP percentage change scores were the most accurate PROMs with a MCID of 16%. The change score for NDI and percentage change scores for NDI, NRS-AP and NRS-NP were slightly higher in the anterior procedure group compared to the posterior procedure group, while remaining PROM estimates were similar across procedure type. The MCID achievement rates at 12-month follow-up ranged from 51% in EMS to 62% in NRS-NP. CONCLUSION The NDI and NRS-NP percentage change scores were the most accurate PROMs to measure clinical improvement after surgery for degenerative cervical myelopathy. We recommend using different cut-off estimates for anterior and posterior approach procedures. A MCID achievement rate of 60% or less must be interpreted in the perspective that the main goal of surgery for degenerative cervical myelopathy is to prevent worsening of the condition.
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Affiliation(s)
- Christer Mjåset
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - John-Anker Zwart
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Frode Kolstad
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Tore Solberg
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
- Department of Neurosurgery, The University Hospital of North Norway, Tromsø, Norway
- The Norwegian Registry for Spine Surgery, The University Hospital of North Norway, Tromsø, Norway
| | - Margreth Grotle
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
- Department of Physiotherapy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
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Anderson DB, Stanford R, Van Gelder JM, Harris IA, Eyles J, Damodaran O, Maher CG, Ferreira ML. How much change in symptoms do spinal surgeons expect following lumbar decompression and microdiscectomy? J Clin Neurosci 2021; 91:243-248. [PMID: 34373035 DOI: 10.1016/j.jocn.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
The study aimed to determine how much change in neurogenic claudication spinal surgeons expect in patients following lumbar decompression for lumbar spine stenosis (LSS), and radicular leg pain following microdiscectomy. Secondary aims were to identify surgeons' preferences regarding surgical techniques for lumbar decompression, and their rating of the quality of current evidence for lumbar decompression. All Australian spine surgeons were invited, of whom 71 completed the survey (31% response rate). Only registered spinal surgeons were included. The online survey, administered using REDCap, included 4 sections: demographics and background; expected change in symptoms on a +/- 100% scale (-100% worst, 0% no change and 100% best possible); surgical preference; and rating of current evidence for lumbar decompression compared with other treatments. There were 71 complete responses, 76% were neurosurgeons (N = 54), predominantly male (96%; N = 68). On average, surgeons expected an 86% (median: 87%, inter-quartile range (IQR): 80%, 91%) improvement in neurogenic claudication following lumbar decompression for LSS and 89% (median: 91%, IQR: 85%, 95%) improvement in radicular pain following microdiscectomy. A multiple linear regression found no surgeon characteristics were associated with expected change following surgery. The preferred surgical technique for LSS was full laminectomy (58%; N = 41). Thirty-five percent of surgeons accurately rated the evidence supporting the superiority of lumbar decompression compared with non-surgical care for LSS as low quality. Spine surgeons expect large symptom improvements following lumbar decompression and microdiscectomy. Understanding of the current evidence was higher for lumbar decompression with fusion, than for decompression alone for LSS.
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Affiliation(s)
- David B Anderson
- Faculty of Medicine and Health, The Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Graduate School of Health, University of Technology Sydney, New South Wales.
| | - Ralph Stanford
- Orthopaedic Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - James M Van Gelder
- Department of Neurosurgery, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia; Sydney Spine Institute, Burwood, New South Wales, Australia
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, New South Wales, Australia; Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jillian Eyles
- Faculty of Medicine and Health, The Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Omprakash Damodaran
- Department of Neurosurgery, Concord General Repatriation Hospital, Concord, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, The Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Identifying biopsychosocial factors that impact decompressive laminectomy outcomes in veterans with lumbar spinal stenosis: a prospective cohort study. Pain 2021; 162:835-845. [PMID: 32925594 DOI: 10.1097/j.pain.0000000000002072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
ABSTRACT One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.
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Evidence-based Advances in Spinal Care: Where Do We Stand Today? Spine (Phila Pa 1976) 2021; 46:E274-E276. [PMID: 33273440 DOI: 10.1097/brs.0000000000003824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Evidence-based Recommendations for Spine Surgery. Spine (Phila Pa 1976) 2021; 46:E277-E285. [PMID: 33290372 DOI: 10.1097/brs.0000000000003838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abbasi H. Physiologic Decompression of Lumbar Spinal Stenosis Through Anatomic Restoration Using Trans-Kambin Oblique Lateral Posterior Lumbar Interbody Fusion (OLLIF): A Retrospective Analysis. Cureus 2020; 12:e11716. [PMID: 33269175 PMCID: PMC7703990 DOI: 10.7759/cureus.11716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Lumbar spinal stenosis (LSS) is one of the most common indications for spinal surgery. Traditionally, decompression is achieved by removing bony and ligamentous structures through open surgery. However, recent studies have shown that symptomatic relief can be accomplished in many patients by increasing intervertebral and interpedicular height using fusion alone. In this study, we evaluate whether trans-Kambin oblique lateral lumbar interbody fusion (OLLIF) can effectively and safely relieve symptoms of LSS when an indication for fusion is present. Methods This is a retrospective single surgeon cohort study of 187 patients with LSS who underwent 189 OLLIF procedures between 2012 and August 2, 2019. Inclusion criteria for this study were age >18 years with symptoms of LSS, including pain, sensory, and motor deficits, and an additional indication for fusion, which included spondylolisthesis, degenerative disk disease, disk herniation, or scoliosis. Exclusion criteria were the bony obstruction of the approach, osteogenic spinal canal stenosis, large facet hypertrophy, and listhesis grade II or greater. The primary outcome was a change in the Oswestry Disability Index (ODI) one year after surgery. Secondary outcomes were the resolution of radiculopathy at the first follow-up visit and one year after surgery, complication rates, surgery time, blood loss, and hospital stay. Results ODI improved from 52% pre-op to 37% at the one-year follow-up. At the first follow-up, radiculopathy had resolved in 39% of patients, and 72% of patients experienced improvement of 50% or greater. One year after surgery, radiculopathy had resolved in 52% of patients and 74% experienced improvement of 50% or greater. Single-level surgeries required 56.4±21.5 minutes, with a mean hospital stay of 1.6‑±2.4 days. Nerve irritation occurred in 12% of patients at the first postoperative follow-up and persisted in 6.8% of patients one year after surgery. There was one case each of persistent weakness at one year, infection, and cage subsidence. Conclusion Trans-Kambin OLLIF delivers anatomic restoration of intradiscal and interpedicular distance, which results in physiologic decompression of lumbar spinal stenosis in patients undergoing lumbar fusion for degenerative or herniated disk disease, spondylolisthesis, or scoliosis. Amongst patients with LSS, OLLIF results in significant improvement of radiculopathy and patient-reported disability in the majority of patients with low rates of long-term complications. Unlike other minimally invasive surgery (MIS) fusions, OLLIF can be safely used from T12-S1.
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Affiliation(s)
- Hamid Abbasi
- Ambulatory Surgical Clinic, Tristate Brain and Spine Institute, Alexandria, USA
- Neurosurgery, Inspired Spine Health, Minneapolis, USA
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Mjåset C, Zwart JA, Goedmakers CMW, Smith TR, Solberg TK, Grotle M. Criteria for success after surgery for cervical radiculopathy-estimates for a substantial amount of improvement in core outcome measures. Spine J 2020; 20:1413-1421. [PMID: 32502657 DOI: 10.1016/j.spinee.2020.05.549] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Defining clinically meaningful success criteria from patient-reported outcome measures (PROMs) is crucial for clinical audits, research and decision-making. PURPOSE We aimed to define criteria for a successful outcome 3 and 12 months after surgery for cervical degenerative radiculopathy on recommended PROMs. STUDY DESIGN Prospective cohort study with 12 months follow-up. PATIENT SAMPLE Patients operated at one or two levels for cervical radiculopathy included in the Norwegian Registry for Spine Surgery (NORspine) from 2011 to 2016. OUTCOME MEASURES Neck disability index (NDI), Numeric Rating Scale for neck pain (NRS-NP) and arm pain (NRS-AP), health-related quality-of-life EuroQol 3L (EQ-5D), general health status (EQ-VAS). METHODS We included 2,868 consecutive cervical degenerative radiculopathy patients operated for cervical radiculopathy in one or two levels and included in the Norwegian Registry for Spine Surgery (NORspine). External criterion to determine accuracy and optimal cut-off values for success in the PROMs was the global perceived effect scale. Success was defined as "much better" or "completely recovered." Cut-off values were assessed by analyzing the area under the receiver operating curves for follow-up scores, mean change scores, and percentage change scores. RESULTS All PROMs showed high accuracy in defining success and nonsuccess and only minor differences were found between 3- and 12-month scores. At 12 months, the area under the receiver operating curves for follow-up scores were 0.86 to 0.91, change scores were 0.74 to 0.87, and percentage change scores were 0.74 to 0.91. Percentage scores of NDI and NRS-AP showed the best accuracy. The optimal cut-off values for each PROM showed considerable overlap across those operated due to disc herniation and spondylotic foraminal stenosis. CONCLUSIONS All PROMs, especially NDI and NRS-AP, showed good to excellent discriminative ability in distinguishing between a successful and nonsuccessful outcome after surgery due to cervical radiculopathy. Percentage change scores are recommended for use in research and clinical practice.
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Affiliation(s)
- Christer Mjåset
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway; Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
| | - John-Anker Zwart
- Faculty of Medicine, University of Oslo, Oslo, Norway; Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Caroline M W Goedmakers
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands; Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, MA, USA
| | - Tore K Solberg
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway; Institute of Clinical Medicine, The Arctic University of Norway (UiT), Tromsø, Norway
| | - Margreth Grotle
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway; Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
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Lewandrowski KU, DE Carvalho PST, DE Carvalho P, Yeung A. Minimal Clinically Important Difference in Patient-Reported Outcome Measures with the Transforaminal Endoscopic Decompression for Lateral Recess and Foraminal Stenosis. Int J Spine Surg 2020; 14:254-266. [PMID: 32355633 DOI: 10.14444/7034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Patient-reported outcome measures (PROMs) have become widely used to better measure patients' judgment of treatment benefits from surgical spine care. The concept of determining the minimal clinically important differences (MCIDs) of PROMs is aimed at assessing the benefits of lumbar spine care that are meaningful to the patient. The goal of this study was to validate the utility of MCIDs of the visual analog score (VAS) and Oswestry Disability Index (ODI) in patients with sciatica-type low back and leg pain due to lateral recess and foraminal stenosis who were treated with directly visualized transforaminal outpatient endoscopic decompression. Methods The retrospective study population consisted of 406 patients on whom PROMs were obtained preoperatively, and again postoperatively at final follow-up. Employing an anchor-based approach with a patient satisfaction index based on the modified Macnab criteria, a receiver operating characteristics (ROC) and area under the curve (AUC) analysis was performed using IBM SPSS 25.0 to define the optimal MCID in VAS and ODI with the transforaminal endoscopy using the top-left-corner criteria and the Youden index. Improvements in walking endurance were recorded as an additional parameter of patient functioning and correlated with PROMs to test for statistical significance. Results The patients' average age was 41.08 years, ranging from 30 to 84 years. The mean follow-up was 33.59 months, ranging from 24 to 85 months, with a standard deviation of 12.79. The MCIDs for VAS and ODI were 2.5 to 3.5 and 15 to 16.5, respectively. Patients were dichotomized as improved (377/406; 92.9%) if they reported excellent (224/406; 55.2%), good (112/406; 27.6%), and fair (41/406; 10.1%) Macnab outcomes. Patients were dichotomized as failed if they reported poor (29/406; 7.1%) Macnab outcomes. Preoperatively, only 32.5% (132/406) of patients had unlimited walking endurance compared to 77.6% (315/406) of patients postoperatively. The ROC and AUC analysis showed better accuracy with the single-integer VAS score (0.926) than with the 10-item ODI score (0.751). Conclusions Transforaminal outpatient endoscopic decompression for symptomatic foraminal and lateral recess stenosis is an effective surgical treatment to alleviate sciatica-type and back symptoms in 92.9% of patients. Of the PROMs analyzed, the VAS provided a more meaningful and accurate reflection of patients' interpretation of outcome with the transforaminal endoscopic spinal decompression procedure than ODI. Understanding which patient expectations drive these MCIDs may aid in replacing open surgeries for sciatica-type low back and leg pain currently preferred by traditional spine surgeons with a personalized early-staged transforaminal endoscopic hybrid decompressive/ablative procedures favored by the authors. These may prove more cost effective by focusing on significant pain generators validated with a diagnostic interventional workup instead of employing image-based indication criteria for surgery.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Arizona; Visiting Professor Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
| | | | - Paulo DE Carvalho
- Department of Neurosurgery, KRH Hospital Nordstadt, Hannover, Germany
| | - Anthony Yeung
- University of New Mexico School of Medicine Department of Neurosurgery Albuquerque, New Mexico; Desert Institute for Spine Care, Phoenix, Arizona
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Lewandrowski KU, Dowling Á, de Carvalho PST, Calderaro AL, Dos Santos TS, de Lima E Silva MS, León JFR, Yeung A. Indication and Contraindication of Endoscopic Transforaminal Lumbar Decompression. World Neurosurg 2020; 145:631-642. [PMID: 32201296 DOI: 10.1016/j.wneu.2020.03.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined. METHODS We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18-90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria. RESULTS Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ2 testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months). CONCLUSIONS We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, Arizona, USA and Visiting Professor, Department Neurosurgery, UNIRIO, Rio de Janeiro, Brazil.
| | - Álvaro Dowling
- Orthopaedic Spine Surgeon, Director of Endoscopic Spine Clinic, Santiago, Chile and Visiting Professor, Department of Orthopaedic Surgery, USP, Ribeirão Preto, Brazil
| | | | - André Luiz Calderaro
- Centro Ortopedico Valqueire, Departamento de Full Endoscopia da Coluna Vertebral, Rio de Janeiro, Brazil
| | | | | | - Jorge Felipe Ramírez León
- Fundación Universitaria Sanitas, Bogotá, D.C., Colombia; Research Team, Centro de Columna, Bogotá, Colombia; Centro de Cirugía de Mínima Invasión, CECIMIN-Clínica Reina Sofía, Bogotá, Colombia
| | - Anthony Yeung
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; Associate, Desert Institute for Spine Care, Phoenix, Arizona, USA
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Dowling Á, Lewandrowski KU, da Silva FHP, Parra JAA, Portillo DM, Giménez YCP. Patient selection protocols for endoscopic transforaminal, interlaminar, and translaminar decompression of lumbar spinal stenosis. JOURNAL OF SPINE SURGERY 2020; 6:S120-S132. [PMID: 32195421 DOI: 10.21037/jss.2019.11.07] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The indications of different endoscopic and endoscopically assisted translaminar approaches for lumbar spinal stenosis are not well-defined, and validated protocols for the use of the transforaminal over the interlaminar approach are lacking. Methods We performed a retrospective study employing an image-based patient stratification protocol of stenosis location (type I-central canal, type II-lateral recess, type III-foraminal, type IV-extraforaminal) and clinical outcomes on 249 patients consisting of 137 (55%) men and 112 (45%) women with an average age of 56.03±16.8 years who underwent endoscopic surgery for symptomatic spinal stenosis from January 2013 to February 2019. The average follow-up of 38.27±27.9 months. The primary clinical outcome measures were the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), and modified Macnab criteria. Results The frequency of stenosis configuration in decreasing order was as follows: type I-121/249; 48.6%, type III-104/249; 41.8%, type II-15/249; 6%, and type IV-9/249; 3.6%. The transforaminal approach (137/249; 55.0%) was used in most type II to IV lesions followed by the interlaminar approach (78/249; 31.3%), and the full endoscopic approach (12/249; 4.8%), and the endoscopically assisted translaminar approach (8/249; 3.2%) which was exclusively used for type I lesions. Macnab outcomes analysis showed Excellent in 47 patients (18.9%), Good in 178 (71.5%), Fair in 18 (7.2%) and Poor in 6 (2.4%), respectively. Paired two-tailed t-test showed statistically significant VAS (5.46±2.1; P<0.0001) and ODI (37.1±16.9; P<0.0001) reductions as a result of the endoscopic decompression surgery. Cross-tabulation of the Macnab outcomes versus the endoscopic approach and surgical technique confirmed beneficial association of the approach selection with Excellent (P=0.001) and Good (P<0.0001) outcomes with statistically significance. Conclusions This study suggests that in the hands of skilled endoscopic spines surgeon use of an image-based stenosis location protocol may contribute to obtaining Excellent and Good clinical outcomes in a high percentage (93%) of patients suffering from lumbar stenosis related radiculopathy. Additional comparative studies should examine the prognostic value of choosing the endoscopic approach on the basis of the proposed four-type stenosis protocol by correlating its impact on outcomes with preoperative diagnostic injections and intraoperative direct visualization of symptomatic pain generators under local anesthesia and sedation.
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Affiliation(s)
- Álvaro Dowling
- Department of Spine Surgery, Endoscopic Spine Clinic, Santiago, Chile.,Department of Orthopaedic Surgery, USP, Ribeirão Preto, Brazil
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson AZ, USA.,Department Neurosurgery, UNIRIO, Rio de Janeiro, Brazil
| | - Fabio Henrique Pinto da Silva
- Department of Orthopaedics, Marcilio Dias Navy Hospital, Rio de Janeiro, Brazil.,Department of Orthopaedics, DWS Spine Clinic Center Santiago, Santiago, Chile
| | - Jaime Andrés Araneda Parra
- Department of Orthopaedics, DWS Spine Clinic Center Santiago and Roberto Del Rio Hospital, Santiago, Chile
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