Length of stay, costs, and complications in lumbar disc herniation surgery by standard PLIF versus a new dynamic interspinous stabilization technique

Evaluation of the efficacy and safety of percutaneous transforaminal endoscopic discectomy for multi-segmental lumbar disc herniation

Objective

To investigate the clinical efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of multi-segmental lumbar disc herniation (msLDH).

Methods

From January 2021 to December 2021, 75 patients with msLDH admitted to Baoding No.1 Hospital of Traditional Chinese Medicine were selected and divided into PTED group (n=40) and posterior lumbar interbody fusion (PLIF) group (n=35) according to different surgical methods. The operative time, intraoperative blood loss, surgical complications, Oswestry disability index (ODI) and Japanese Orthopedic Association score (JOA) scores were compared between the two groups.

Results

In the PTED group, the average operation time was 57.45±12.01minutes, and the average intraoperative blood loss was 50.57±16.69ml. There were three patients with surgical complications, including one case of hematoma, one case of aggravation of neurological symptoms and one case of new onset of neurological symptoms. In the PLIF group, there were 12 cases undergoing single-segment operation, 15 cases undergoing double-segment operation and 8 cases undergoing three-segment operation, the average operation time was 137.26±34.64minutes, and the average intraoperative blood loss was 456.06±33.06ml, there were four cases of wound fat liquefaction or delayed healing, two cases of hematoma, and three cases of exacerbation of original neurological symptoms or new neurological symptoms. At one month, six months, and one year of postoperative, the ODI and JOA scores of the two groups were significantly improved compared with those preoperative, and the ODI scores of the PTED group were better than those of the PLIF group (t=3.131, 2.263, 3.768, all P<0.05).

Conclusion

The surgical effect of PTED in the treatment of LDH is similar to that of PLIF. However, PTED has the advantages of short operation time, less blood loss, fewer surgical complications, and high surgical safety. It is worthy of clinical promotion.

Interspinous Process (ISP) Devices in Comparison to the Use of Traditional Posterior Spinal Instrumentation

A systematic literature review was conducted on studies comparing interspinous process (ISP) devices to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct), in terms of indications of use, complications, pain assessment, estimated blood loss, length of hospital stay, reoperation rates, and return to work. The objective was to analyze, evaluate and summarize the current published literature on the proposed efficacy and clinical and surgical long-term outcomes of the ISP device in comparison to the traditional posterior spinal instrumentation (pedicle screw-rod construct). The ISP device is a minimally invasive and less disruptive alternative to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). However, very few published literature studies to date have reported the comparison of ISPs in terms of efficacy and clinical and surgical outcomes, to traditional posterior spinal instrumentation. A systematic literature review was performed in PubMed and Google Scholar to evaluate the results of published research that meet the defined inclusion and exclusion criteria and to analyze clinical indications and surgical outcomes of the ISP device compared to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). Inclusion criteria included keywords such as "ISP device, ISP, posterior spinal instrumentation, pedicle screw fixation, bilateral pedicle screws, interbody fusion with posterior spinal instrumentation, lumbar spinal stenosis, and posterior lumbar stability." No exclusion criteria keywords were included in this literature review. ISPs provide a high degree of spinal stability in multiple planes, including a decreased range of motion restriction in flexion-extension, and comparable results to bilateral pedicle screw (BPS) in axial rotation. The use of the ISP device in adjunct with an interbody fusion, ensures less estimated operative blood loss (EBL), shorter operative time, less bony exposure without the need for extensive soft tissue or muscle retraction, a decrease in the rate of pseudoarthrosis, and a shorter length of hospital stay (LOHS) when compared to the traditional posterior instrumentation (pedicle screw-rod construct). Based on the various published literature reviews noted throughout this research paper, it is safe to conclude, that an ISP device that is accompanied by interbody fusion, including posterior approaches posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF); anterior approaches such as anterior interbody fusion (ALIF), and lateral approaches including direct lateral interbody fusion (DLIF), lateral lumbar interbody fusion (LLIF), extreme lateral interbody fusion (XLIF), is considered a credible and an effective minimally invasive option for the treatment of mild to moderate lumbar stenosis and stable low-grade spondylolisthesis (less than two) when compared to the traditional posterior spinal instrumentation of a pedicle screw-rod construct. Surgeons that are relatively new to the ISP technologies for spinal instrumentation would likely benefit from more clinical and surgical evidence of safety and efficacy in published peer-reviewed medical literature. Further clinical trials are needed to manifest the efficacy of ISPs regarding postoperative outcomes when compared to traditional posterior instrumentation techniques (pedicle screw-rod construct) with adjunct interbody fusions.

Preoperative and Postoperative Spending Among Working-Age Adults Undergoing Posterior Spinal Fusion Surgery for Degenerative Disease

OBJECTIVE

To investigate the health care resource utilization and the associated 6 months preoperative and 6 months postoperative spending among patients undergoing posterior lumbar fusion.

METHODS

We retrospectively reviewed a private insurance claims database for patients who underwent single-level posterior spinal fusion from January 2011 to December 2015. Outpatient health services, prescription pain medications, and inpatient admissions were assessed.

RESULTS

Among 25,401 patients (mean age, 52 years; 58% female) in the final cohort, median spending during the period from 6 months before surgery to 6 months after surgery was $60,714 (interquartile range [IQR], $46,961-$79,892)/patient. Preoperative spending accounted for 7% ($121 million) of the total costs, and postoperative spending accounted for 8% ($135 million). Median preoperative spending was $3566 (IQR, $2144-$5857) per patient, with imaging accounting for the highest proportion (33%) of preoperative spending. In the 6 months period preceding surgery, 46% patients received injections and 47% received physical therapy. The median postoperative spending was $1954/patient (IQR, $735-$4416). Total postoperative spending was significantly higher among those not discharged home (median, $7525; IQR, $6779-$19,602) compared with those discharged home (median, $1617/patient; IQR, $648-$4033) and home with home care services (median, $2921; IQR, $1406-$5662) (P < 0.001).

CONCLUSIONS

Unplanned readmission after posterior spinal fusion was the highest contributor to postoperative spending and the second highest contributor to overall costs. Understanding factors that contribute to the costs in the preoperative and postoperative period in patients undergoing single-level posterior lumbar fusion for degenerative pathology is essential to identify targets for cost containment.

RETURN TO ADVANCED STRENGTH TRAINING AND WEIGHTLIFTING IN AN ATHLETE POST-LUMBAR DISCECTOMY UTILIZING PAIN NEUROSCIENCE EDUCATION AND PROPER PROGRESSION: RESIDENT'S CASE REPORT

STUDY DESIGN

Case Report.

BACKGROUND AND PURPOSE

The use of pain neuroscience education (PNE) is indicated when there are psychosocial contributions to a person's pain experience. The scientific literature has established the efficacy of the use of PNE in a population with chronic pain but there is a paucity of evidence to support the use of PNE in athletic populations. The purpose of this case report is to describe the use of PNE and graded exposure exercises specific to an athlete returning to Olympic weightlifting.

CASE DESCRIPTION

The patient underwent an L5-S1 discectomy to resolve paresthesia in his leg, completed a bout of post-operative rehabilitation but returned 15 months after the surgery. He presented with the chief complaint of low back tightness and fear of lumbar flexion. When asked to touch his toes during the lumbar flexion range of motion examination, he demonstrated aberrant lumbar movement by hinging at the hips with a straight back due to fear that flexing would damage his lumbar spine. The patient was seen for four weeks with a focus on PNE and graded exposure to weightlifting activities.

OUTCOMES

The patient returned to Olympic weightlifting and decreased his Fear Avoidance Behavior Questionnaire (FABQ) score from 22 to 4 during the course of physical therapy. His Tampa Scale of Kinesiophobia (TSK) score also decreased from 55 to 31. By discharge, he was able to bend at the lumbar spine with full flexion and no longer believed the motion to cause damage.

DISCUSSION

The case is unique because it describes the implementation of PNE in an athlete returning to weightlifting, and the scientific literature for use of PNE in this population is lacking. The identification of kinesiophobia and implementation of PNE and graded exposure exercises lead to an optimal outcome for this patient.

LEVEL OF EVIDENCE

Level 4.

Comparison of Nitinol and Titanium Nails Effectiveness for Lumbosacral Spine Fixation in Surgical Treatment of Degenerative Spine Diseases

Relevance. Surgical decompression and decompression with stabilization are highly effective for treatment of spinal canal stenosis at the level of lumbar spine. However, complications developing after application of rigid fixation systems resulted in active introduction of dynamic implants into clinical practice.

Purpose of the study — to compare effectiveness of nitinol and titanium nails for lumbosacral fixation in surgical treatment of degenerative spine diseases.

Materials and methods. 220 patients who underwent surgeries in 4 hospitals were randomized into two groups, each consisting of 110 patients (1:1 ratio): a group of patients who underwent stabilization of the vertebral motor segments with rods of nitinol with the required volume of decompression at the operation level and a group of patients who underwent stabilization of the vertebral motor segments with standard rods of titanium with the required volume of decompression at the intervention level. Patients suffered clinically significant spinal canal stenosis in one or two adjacent segments: from L3 to S1. Outcomes were evaluated during three years postoperatively by VAS scale for spine and lower limbs, and by ODI and SF-36 scales.

Results. All scales demonstrated better values in both groups of patients, namely, significant decrease of pain syndrome and improvement in mental and physical health. X-ray examination of all patients during the study period demonstrated restoration of lumbar lordosis. Group of patients with dynamic nails featured less complications rate related to metal implants including adjacent segment disease.

Conclusion. Transpedicular fixation of lumbosacral spine by nitinol nails is an effective technique allowing to preserve motion along with stable fixation.