Postoperative spinal orthosis may not be necessary for minimally invasive lumbar spine fusion surgery: a prospective randomized controlled trial

Trends in Spinal Orthosis Utilization Among Patients Insured Through Medicare Part B

STUDY DESIGN

Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Data Set.

OBJECTIVE

To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period.

SUMMARY OF BACKGROUND DATA

Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed.

MATERIALS AND METHODS

Health care common procedure coding system codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. In addition, a neurosurgical CO analysis based on subclassifications of cervical bracing was performed. Linear trendlines were implemented to elucidate and present trends by slope (β).

RESULTS

Among 332,241 claims, decreases in CO (β=-0.3387), TLSO (β=-0.0942), LO (β=-0.3485), and LSO (β=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (β=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (β=-7.9208), family medicine (β=-1.0097), emergency medicine (β=-2.1958), internal medicine (β=-1.1151), interventional pain management (β=-5.0945), and chiropractic medicine (β=-49.012), and increases among orthopedic surgery (β=5.5891), pain management (β=30.416), physical medicine and rehabilitation (β=4.6524), general practice (β=79.111), and osteopathic manipulative medicine (β=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis of subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (β=-1.7641), semirigid (β=-0.6157), and collar bracing (β=-2.7603), and an increase in multipost collar bracing (β=2.2032) per 100 neurosurgical cervical orthosis claims.

CONCLUSIONS

While utilization of spinal orthosis decreased between 2010 and 2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective health care spending.

Post-operative bracing following adult spine deformity surgery: Results from the AO Spine surveillance of post-operative management of patients with adult spine deformity

STUDY DESIGN

Cross-sectional international survey with a literature review.

OBJECTIVES

While some surgeons favor spine bracing after surgery for adult spine deformity (ASD) to help prevent mechanical failures, there is a lack of evidence. The objective of the present study was to better understand the current trend in the use of bracing following ASD surgery based on an international survey.

METHODS

An e-mail-based online survey was conducted among over 6000 international AO Spine members regarding the post-operative management of patients with ASD. The details of brace prescription, indications and influencing factors were solicited. Descriptive data were summarized based on different demographic groups and fusion levels for the responding surgeons who annually perform at least 10 long-segment fusions of >5 levels extending to the pelvis.

RESULTS

A total of 116 responses were received, including 71 surgeons (61%) who used post-operative bracing for >5 levels of long fusion. The most common reason for bracing was pain management (55%) and bone quality was the strongest influencing factor (69%). Asia-Pacific surgeons had the highest rate of bracing (88%), while North American surgeons had the lowest (45%). The most common type of brace used were TLSO for cases with an uppermost instrumented vertebra (UIV) in the low- or mid-thoracic spine and a cervical brace for UIV at T1-3. The majority (56%) used bracing for 6-12 weeks after surgery.

CONCLUSIONS

The present survey demonstrated significant interest in bracing following ASD surgery, however, there is substantial variability in post-operative bracing practice. A formal study on the role of bracing in ASD surgery is needed.

To corset or not to corset after lumbar spine fixation surgery?: A prospective randomized clinical trial and literature review

PURPOSE

Orthosis after lumbar fusion surgery is common. However, the evidence for benefit remains to be determined, especially in tropical areas with heavy workers. To investigate postoperative orthosis and whether it affects pain improvement, quality of life, and fusion rate.

METHOD

From May 2021 to May 2022, this single-center prospective randomized clinical trial enrolled 110 patients. We excluded 9 patients, and 101 people were analyzed finally. Corset group, in which participants used a corset for 3 months postoperatively; Non-corset group, in which participants didn't wear any orthosis. ODI and VAS scale were recorded before the surgery: 2 weeks, 1 month, 3 months, half a year, and 1 year postoperatively. The lumbar X-ray was done before the surgery, 6 months postoperatively. All complications in 1 year were recorded.

RESULTS

Significant decrease in VAS score in the non-corset group since post-operation day 5 (corset group 3.44 ± 1.77, non-corset group 3.36 ± 1.75, P = .0093) during admission, and also a decrease in admission duration (corset group 11.08 ± 2.39, non-corset group 9.55 ± 1.75, P = .0004) were found. There was a significantly better ODI score in the non-corset group since post-operation 1 month, while in the corset group until post-operation 3 months. Both groups had no significant difference in satisfaction, complication rates, and X-ray results, such as fusion, angular rotation, sagittal transition, and slip in the neutral position.

CONCLUSION

After the transpedicular screw fixation with posterolateral fusion surgery for degenerative spondylolisthesis, non-orthosis is a safe strategy. It can reduce the admission duration and has the trend for better functional outcomes.

Effectiveness of lumbar braces after lumbar surgery: a systematic review and meta-analysis

OBJECTIVE

To systematically analyze the effectiveness of lumbar braces in patients after lumbar spine surgery.

METHODS

The databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), were searched to identify the randomized controlled trials (RCTs), case-series or case-control studies on the use of lumbar braces after lumbar spine surgery. The two authors independently assessed the quality of the included study and extracted the data. The statistical analysis was performed using Revman 5.4 software.

RESULTS

9 English papers and 1 Chinese paper were included in the present work, involving a total of 2646 patients (2181 in the experimental group and 465 in the control group). The differences in preoperative VAS, postoperative VAS, preoperative ODI, postoperative ODI, length of hospital stay, postoperative complications, and surgical comparison were not statistically significant (p > 0.05). However, postoperative surgical site infection incidence was lower in the lumbar brace group than those without lumbar brace (p < 0.05).

CONCLUSION

Whether or not the use of lumbar braces after lumbar fixation has a negligible impact on clinical outcomes was studied. Subsequent studies could further demonstrate whether the use of lumbar braces after lumbar surgery could reduce the incidence of surgical site infections.

Postoperative Spinal Orthoses: Types and Outcomes

INTRODUCTION

Postoperative bracing (POB) after spinal surgery is a common practice that has been used for many decades. In the past few years, the indications, types, and outcomes of POB have been heavily questioned after many studies revealed no consistent evidence to support or refute the use of spinal orthoses after surgery.

SUMMARY

Currently, there are no indications of the type, duration, or indication for many spinal orthoses and few studies have assessed their efficacy. Although much of the literature lacks adequate comparisons of brace types or specific indications, POB is still widely used for various surgical procedures. This study evaluated the current evidence concerning POB of the cervical, thoracic, and lumbosacral spine.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Does the use of postoperative brace help preventing mechanical complications following adult deformity surgery?

PURPOSE

There is scarce information regarding the effectiveness of postoperative braces in decreasing mechanical complications and reinterventions following adult deformity surgery.

METHODS

Retrospective matched cohort study from a prospective adult deformity multicenter database. We selected operated patients, fused to the pelvis, > 6 instrumented levels, and minimum 2 year follow-up. Three hundred and eighty patients were separated into two groups (Brace-3 months TLSO-vs No Brace) and then matched controlling for age, gender and frailty. We studied demographic, intraoperative, and postoperative spinopelvic parameters. Both groups were compared regarding complications and reinterventions in the first 2 postoperative years, using univariate and multivariate logistic regression analysis.

RESULTS

We finally analyzed 359 matched patients, mean age of 65.3 ± 8.9 years, frailty-index (0.43 ± 0.15), and mostly females (84%). 224 patients wore a postoperative brace (B) and 135 didn't (NoB). They showed no difference in intraoperative variables and postoperative spinopelvic alignment. They differed (P < 0.05) in: Pelvic incidence (B:58° ± 13 vs NoB:54.5° ± 13); BMI (B:25.8 ± 4 vs NoB:27.4 ± 5); upper instrumented vertebra (B:81.7% T8-L1 vs NoB:72.6% T8-L1), and the use of multiple rods (B:47.3% vs NoB:18.5%). Univariate analysis showed a higher rate of mechanical complications and reinterventions when not using a brace. As well as higher NRS-back and leg pain at 6 weeks. However, multivariate analysis selected the use of multiple rods as the only independent factor protecting against mechanical complications (OR: 0.38; CI 95% 0.22-0.64) and reinterventions (OR: 0.41; CI 95% 0.216-0.783).

CONCLUSION

After controlling for potential confounders, our study could not identify the protective effect of postoperative braces preventing mechanical complications and reinterventions in the first two postoperative years.