Criteria for determining if a treatment for pain works

Claims that a treatment works are hollow unless qualified in terms of: in what respects, by how much, how often, and for how long. Essential co-requisites for improvements in pain are improvements in function, psychological distress, and use of health care. Validated instruments are available for these outcome measures. Mean scores and p-values are not informative. Categorical data are required to reveal by how much a treatment works and how often. In order to provide a full picture, outcomes need to be followed until they plateau. Readers of studies should not rely on what authors claim. Instead, readers should demand comprehensive, transparent data on outcomes so that they can decide for themselves if a treatment works to their satisfaction.

Management of degenerative spondylolisthesis: development of appropriate use criteria

BACKGROUND CONTEXT

Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized.

PURPOSE

The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process was used.

METHODS

The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Time Course Observation of Outcomes between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion

The purpose of this study is to compare the long-term patient-outcomes, spinal fusion, and incidence of adjacent segment degeneration (ASD) between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open posterior lumbar interbody fusion (O-PLIF). We retrospectively reviewed 70 consecutive cases who underwent single-level MIS-TLIF or O-PLIF from March 2010 to July 2013. All the patients achieved a minimum of 5-year follow-up. Data collected for each patient included demographic data, perioperative data, and complications. Clinical outcomes were evaluated with Oswestry disability index and visual analogue scale (VAS). Radiological outcomes included fusion rate and ASD. About 34 patients of MIS-TLIF and 36 patients of O-PLIF were enrolled. Higher Charlson comorbidity index scores were noted in MIS-TLIF than in O-PLIF. Blood loss was significantly lower in MIS-TLIF than O-PLIF. There were significant improvements in clinical and radiological outcomes in both groups. At 6 months, in MIS-TLIF group had significantly lower VAS for back pain and disc height compared with in O-PLIF group. The fusion rate was similar between the two groups at 5-year follow-up. Although the total complication rates were similar between the two groups, both the incidence of ASD was significantly higher in O-PLIF group than MIS-TLIF group (P = 0.032). In conclusion, this study indicates that MIS-TLIF is comparable to O-PLIF in terms of fusion rates and clinical outcomes in single-segment degenerative lumbar diseases. In addition, compared with O-PLIF, MIS-TLIF has the advantages of lesser blood loss, faster recovery, and lower incidence of ASD.

The Modified 5-Item Frailty Index: A Concise and Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity Following Elective Posterior Lumbar Fusions

BACKGROUND

The modified 5-item frailty index (mFI-5) is a concise comorbidity-based risk stratification tool that has been shown to predict the occurrence of adverse outcomes following various orthopedic surgeries.

METHODS

The 2012-2016 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing an elective 1- to 2-level posterior lumbar fusion for degenerative lumbar pathology. The mFI-5 score was calculated based on the presence of the 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on postoperative morbidity while controlling for baseline clinical characteristics.

RESULTS

Increasing mFI-5 score versus mFI-5 = 0 was associated with higher odds of any complication (mFI-5 ≥2: odds ratio [OR] 1.45; mFI-5 = 1: OR 1.22), 30-day readmissions (mFI-5 ≥2: OR 1.46; mFI-5 = 1: OR 1.18), and nonhome discharge (mFI-5 ≥2: OR 1.80; mFI-5 = 1: OR 1.16). Higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, unplanned reoperation, any medical complication, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, bleeding requiring transfusion, sepsis, and septic shock.

CONCLUSIONS

Higher mFI-5 scores were associated with increased postoperative morbidity following elective 1- to 2-level posterior lumbar fusions.

Optimal medial transforaminal lumbar interbody fusion approach with five extensive options: A simulated study on three-dimensional digital reconstructed images

Objective

The objective of this study is to use 3D digital lumbar models to investigate and simulate the optimal posterior operative approach for safe decompression and insertion of an interbody cage.

Methods

Thirty lumbar spine (L3-S1) computed tomography data are collected for 3D reconstruction. We cut medial half part of the superior facet and define the distance between the margin of the operative side of the spinous process and the medial margin of the cut superior facet as "medial distance (MD)". Then, we cut the total superior facet and define the distance between the margin of the operative side of the spinous process and the lateral side of the junction of the pedicle and the vertebral body as "extend distance (ED)". The feasible insertion of the current standard width size (10 mm and 12 mm) interbody cages was assessed by the two aforementioned MD and ED approaches. Besides the ED, we also simulate four other extensive options of lateral upper, lateral lower, vertical upper and lower and transmedian contralateral decompression on 3D digital lumbar model.

Results

The MD increased from 13.48 ± 1.28 mm at L3/4 to 18.05 ± 1.43 mm at L5/S1, and the ED increased from 16.64 ± 1.34 mm at L3/4 to 21.12 ± 1.62 mm at L5/S1. To insert a 10-mm-wide cage, 16.7% (left) and 13.3% (right) of MD for L3/4 is not enough, 60.0% (left) and 46.7% (right) of MD for L3/4 is subsafe, 13.3% (left) and 16.7% (right) of MD for L4/5 is subsafe and all others are safe. To insert a 12-mm-wide cage, 76.7% (left) and 60.0% (right) of MD for L3/4 is not enough, 20.0% (left) and 30.0% (right) of MD for L3/4 is subsafe, 13.3%% (left) and 16.7% (right) of MD for L4/5 is not enough, 63.3% (left) and 56.7% (right) of MD for L4/5 is subsafe and 6.7% (left) and 10.0% (right) of MD for L5/S1 is subsafe, whereas 33.3%% (left) and 30.0% (right) of ED for L3/4 is subsafe, 3.3% (left) and 3.3% (right) of ED for L4/5 is subsafe and all others are safe. Besides the ED, on 3D models, four other extensive options could be simulated too and may need to be performed for different special individuals.

Conclusion

Our 3D digital image study provides a feasible optimal medial transforaminal lumbar interbody fusion approach with five extensive options on lower lumbar region. It can provide safe lumbar decompression and interbody fusion in most population. In addition, surgeons can choose the different extensive options for special individual conditions.

The translational potential of this article

Transforminal lumbar interbody fusion is very common used for lumbar degenerative diseases. The optimal medial transforminal lumbar interbody fusion with five options provide a safe and precise approach for surgeons in treatment of lumbar degenerative diseases.

Clinical outcomes during the learning curve of MIDline Lumbar Fusion (MIDLF®) using the cortical bone trajectory

OBJECTIVE

The objective of this study is to review the clinical outcomes of a novel minimally invasive surgery (MIS) technique for the treatment of instability of the lumbar spine using the cortical bone trajectory (CBT). We present a prospective review of the clinical outcomes from the first 25 consecutive cases in a single unit during the initial learning phase.

MATERIALS AND METHODS

The investigation group included the first 25 patients (eight males and 17 females) who underwent MIDLF® since the introduction of this technique in a single unit. All patients were operated on by the same surgeon. Patients' demographics, as well as duration their surgery, intraoperative blood loss, duration of hospitalization, and complications were analyzed. From the patients' satisfaction survey; pre and post-operative analgesics use, visual analogue scale (VAS) score for both back pain and radicular symptoms, as well as the Oswestry disability index (ODI) were measured and analyzed.

RESULTS

There was a clear improvement in all measured parameters. The median intraoperative blood loss was 250 ml (200-700) with an average operative time of 190 (±46) and 237 (±14) min for one- and two-level fixation respectively and a median hospital stay of 2 days (1-12) inclusive of the day of surgery. The mean preoperative ODI was 59 % (±18.7) versus 34 % (±19.5) post-operatively. In this series, 84 % of the patients (n = 21) reported a significant reduction in the use of analgesia, and 44 % (n = 11) reported total freedom from intake of painkillers. The median postoperative pain-free walking distance increased from 50 (0-3520) to 1000 (0-8880) yards. Three complications were reported without any significant postoperative morbidity. While in this case series the preoperative ODI and back pain VAS significantly predicted the post-operative variable, the same could not be demonstrated for leg pain, preoperative walking distance, number of pain killers, or the patient body mass index (BMI).

CONCLUSIONS

Our results indicate that lumbar instrumentation using CBT is safe and effective with comparable results to those published for posterior lumbar interbody fusion (PLIF) even with the learning curve of new procedures. Patients who underwent a MIDLF® needed a shorter operative time, and they were mobilized and discharged quicker, with figures almost similar to those from non-instrumented surgery. While in this case series the preoperative ODI and back pain VAS significantly predicted the post-operative variable, the same could not be demonstrated for leg pain, preoperative walking distance, number of pain killers, or the patient BMI. Larger studies with longer follow-up are needed in order to better understand and assess the possible advantages of this technique.

Do Trunk Muscles Affect the Lumbar Interbody Fusion Rate?: Correlation of Trunk Muscle Cross Sectional Area and Fusion Rates after Posterior Lumbar Interbody Fusion Using Stand-Alone Cage

Objective

Although trunk muscles in the lumbar spine preserve spinal stability and motility, little is known about the relationship between trunk muscles and spinal fusion rate. The aim of the present study is to evaluate the correlation between trunk muscles cross sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion (PLIF) using stand-alone cages.

Methods

A total of 89 adult patients with degenerative lumbar disease who were performed PLIF using stand-alone cages at L4–5 were included in this study. The cross-sectional area of the psoas major (PS), erector spinae (ES), and multifidus (MF) muscles were quantitatively evaluated by preoperative lumbar magnetic resonance imaging at the L3–4, L4–5, and L5–S1 segments, and bone union was evaluated by dynamic lumbar X-rays.

Results

Of the 89 patients, 68 had bone union and 21 did not. The MCSAs at all segments in both groups were significantly different (p<0.05) for the PS muscle, those at L3–4 and L4–5 segments between groups were significantly different (p=0.048, 0.021) for the ES and MF muscles. In the multivariate analysis, differences in the PS MCSA at the L4–5 and L5–S1 segments remained significant (p=0.048, 0.043 and odds ratio=1.098, 1.169). In comparison analysis between male and female patients, most MCSAs of male patients were larger than female's. Fusion rates of male patients (80.7%) were higher than female's (68.8%), too.

Conclusion

For PLIF surgery, PS muscle function appears to be an important factor for bone union and preventing back muscle injury is essential for better fusion rate.

Comparison of the different surgical approaches for lumbar interbody fusion

This review will outline the history of spinal fusion. It will compare the different approaches currently in use for interbody fusion. A comparison of the techniques, including minimally invasive surgery and graft options will be included. Lumbar interbody fusion is a commonly performed surgical procedure for a variety of spinal disorders, especially degenerative disease. Currently this procedure is performed using anterior, lateral, transforaminal and posterior approaches. Minimally invasive techniques have been increasing in popularity in recent years. A posterior approach is frequently used and has good fusion rates and low complication rates but is limited by the thecal and nerve root retraction. The transforaminal interbody fusion avoids some of these complications and is therefore preferable in some situations, especially revision surgery. An anterior approach avoids the spinal cord and cauda equina all together, but has issues with visceral exposure complications. Lateral lumbar interbody fusion has a risk of lumbar plexus injury with dissection through the psoas muscle. Studies show less intraoperative blood loss for minimally invasive techniques, but there is no long-term data. Iliac crest is the gold standard for bone graft, although adjuncts such as bone morphogenetic proteins are being used more frequently, despite their controversial history. More high-level studies are needed to make generalisations regarding the outcomes of one technique compared with another.

Minimally invasive versus open posterior lumbar interbody fusion: a systematic review

BACKGROUND

Although conventional open posterior lumbar interbody fusion (open PLIF) is efficacious in management of lumbar spinal instability, concerns exist regarding lengthy hospital stays, blood loss, and postoperative complications. Minimally invasive posterior lumbar interbody fusion (MIS PLIF) may be able to address these concerns, but the research on this topic has not been systematically reviewed.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether MIS PLIF or open PLIF results in (1) better perioperative parameters, including blood loss, operative times, and length of hospital stay; (2) improved patient-reported outcome scores; and (3) improved disc distraction and (4) frequency of reoperation and complications when compared with open PLIF procedures.

METHODS

A literature search of the MEDLINE database identified seven studies that met our inclusion criteria. A total of seven articles were included; quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) scale. Descriptive statistics were used to describe the included articles.

RESULTS

In most studies, MIS PLIF was associated with decreased blood loss and shorter hospital stay but longer operative times. MIS PLIF resulted in better patient-related outcomes when compared with open PLIF in two studies in the short term, but most of the studies in this review found no short-term differences, and there was no difference at long-term followup in any studies. There was no significant difference in disc distraction. Both techniques appeared to have similar complication rates and reoperation rates.

CONCLUSIONS

Based on the available evidence, which we restricted to prospective and retrospective studies with control groups, but did not include any well-designed randomized trials, MIS PLIF might lead to better perioperative parameters, but there was little evidence for improved patient-reported outcomes in the MIS groups. Randomized controlled trials are needed to compare these two surgical techniques.