Management of degenerative lumbar spinal stenosis: an evidence-based review

Role of unilateral partial facet joint preservation in postero-lateral approach lumbar interbody fusion for patients with degenerative lumbar spinal stenosis presenting bilateral lower limb symptoms: a retrospective study

BACKGROUND

Posterolateral decompression and fusion with internal fixation is a commonly used surgical approach for treating degenerative lumbar spinal stenosis (DLSS). This study aims to evaluate the impact of preserving a portion of the unilateral facet joint during decompression on surgical outcomes and long-term recovery in patients.

METHODS

This study analyzed 73 patients with DLSS accompanied by bilateral lower limb neurological symptoms who underwent single-level L4/5 posterolateral decompression and fusion surgery from January 2022 to March 2023. Patients were categorized into two groups based on the type of surgery received: Group A comprised 31 patients who underwent neural decompression without facet joint preservation, while Group B consisted of 42 patients who underwent neural decompression with preservation of partial facet joints on one side. Regular follow-up evaluations were conducted, including clinical and radiological assessments immediately postoperatively, and at 3 and 12 months thereafter. Key patient information was documented through retrospective chart reviews.

RESULTS

Most patients in both groups experienced favorable surgical outcomes. However, four cases encountered complications. Notably, during follow-up, Group B demonstrated superior 1-year postoperative interbody fusion outcomes (P < 0.05), along with a trend towards less interbody cage subsidence and slower postoperative intervertebral disc height loss. Additionally, Group B showed significantly reduced postoperative hospital stay (P < 0.05).

CONCLUSION

Under strict adherence to surgical indications, the posterior lateral lumbar fusion surgery, which preserves partial facet joint unilaterally during neural decompression, can offer greater benefits to patients.

Can magnetic resonance imaging findings effectively diagnose the instability observed on radiographs in patients with degenerative lumbar spinal stenosis?

BACKGROUND

Degenerative lumbar spinal stenosis (LSS) is a common condition that involves the narrowing of the spinal canal. Diagnosing instability traditionally requires standing lateral radiographs to detect dynamic translation, but there is debate about relying solely on radiographs due to challenges like patient discomfort and radiation exposure. This study aimed to evaluate if Magnetic Resonance Imaging (MRI) findings could effectively diagnose instability observed on radiographs.

METHODS

We reviewed 478 consecutive patients with degenerative LSS who had surgery at our institution. Instability was defined as a sagittal translation exceeding 3 mm on standing lateral radiographs in both extension and flexion. Patients were divided into stable (those with < 3 mm translation) and unstable groups (those with > 3 mm translation). The study assessed potential variables for instability, including MRI findings like facet joint effusion, facet joint angle, disk height index, intradiscal vacuum presence, endplate sclerosis, ligamentum flavum hypertrophy, and multifidus muscle fatty degeneration, comparing these factors between the two groups.

RESULTS

A total of 478 consecutive patients diagnosed with degenerative Lumbar Spinal Stenosis (LSS) were included. The average age of the patients was 66.32 years, with 43.3% being male. Approximately 27.6% of the cases exhibited signs of instability on the standing lateral radiograph during extension and flexion. The multivariate analysis using binary logistic regression revealed that facet joint effusion (odds ratio [OR] 2.73; 95% confidence interval [CI] 1.27-3.94; P = 0.002), disk height index (OR 2.22; 95% CI 1.68-3.35; P = 0.009), and the presence of the Vacuum sign (OR 1.77; 95% CI 1.32-2.84; P = 0.021) were identified as factors associated with instability.

CONCLUSIONS

Our findings showed thata higher facet joint effusion, the presence of Vacuum sign, and a greater Disk Height Index were associated with the presence of instability on the standing lateral radiograph in extension and flexion in patients with degenerative LSS.

Remarkable recovery of lower extremity motor impairment in degenerative disc disease after percutaneous laser disc decompression combined with umbilical cord-derived mesenchymal stem cells implantation: A case report

INTRODUCTION AND IMPORTANCE

Degenerative disc disease (DDD) is a common cause of low back pain, often leading to significant discomfort for patients. Current treatment options such as spinal fusion and physical therapy focus on symptom management rather than addressing the underlying degeneration. Percutaneous laser disc decompression (PLDD) has shown efficacy in treating radicular pain associated with disc herniation. However, there is a growing interest in utilizing tissue engineering approaches to reverse the pathological process of DDD. While results in larger vertebrates have been inconsistent, mesenchymal stem cells (MSCs) have demonstrated promise in small animal models.

CASE PRESENTATION

A 46-year-old male presented with low back pain as well as urinary and fecal incontinence. Magnetic resonance imaging revealed disc bulging and foraminal stenosis at the L2-L4 levels. The patient underwent PLDD combined with umbilical cord-derived mesenchymal stem cells (UC-MSCs) injection, which later resulted in significant pain reduction and improved motor function. At six months of follow-up, the patient reported sustained pain relief and functional improvement.

CLINICAL DISCUSSION

Percutaneous decompression techniques not only substantially reduce intradiscal pressure and facilitate the implosion of herniation inward but also concurrently expedite the degeneration of the intervertebral disc. Therefore, in addition to performing PLDD, stem cell injection is also carried out. This report underscores the importance of integrating mechanical and biological interventions for degenerative disc diseases, suggesting PLDD combined with MSC therapy as a promising strategy for managing DDD and potentially reversing its progression. We found that the patient had decreased pain postoperatively; he no longer complained of pain after six months of follow-up.

CONCLUSION

PLDD combined with UC-MSCs might be an alternative treatment for patients with DDD. In addition to mechanical treatment, biological treatment with MSC injections is believed to be a potent combination for treating degenerative diseases such as DDD.

Pharmacopuncture Therapy as an Adjunctive Treatment for Patients with Lumbar Spinal Stenosis: A Pragmatic Randomized Controlled Pilot Trial

Purpose

Pharmacopuncture therapy (PPT) combines medicinal extracts with acupuncture and is widely used as an adjunct in clinical practice. This study assessed the safety and feasibility of PPT in addition to conventional Korean Medicine treatment (CKMT), including electroacupuncture, cupping and infra-red, for lumbar spinal stenosis (LSS).

Patients and Methods

Forty patients diagnosed with LSS were randomly assigned to undergo PPT with CKMT (experimental group) or CKMT alone (control group) at a 1:1 ratio, receiving 10 sessions of each intervention over five weeks. The primary clinical outcome was measured using the 100-mm Visual Analog Scale (VAS) for buttock and leg pain five weeks post-treatment. Secondary outcomes included clinically important difference (CID), Zurich Claudication Questionnaire, self-reported walking capacity, Modified-Modified Schober test, EuroQol 5-dimension 5-level questionnaire, and the patient's global impression of change. The adverse events were assessed at each visit. The analysis of covariance was conducted to compare between two groups.

Results

Intervention completion rates were 95% and 100% in the experimental and control groups, respectively. No statistically significant differences were found between groups regarding the primary outcome (adjusted mean difference: 8.0; 95% confidence interval: -1.4-17.4). The mean difference in the 100-mm VAS for low back pain at week 5 (adjusted mean difference: 12.9; 95% confidence interval: 2.4-23.4) and the proportion of patients who reached the minimum CID was higher in the experimental group than in the control group. However, no significant differences were observed with other secondary outcomes. One patient in the experimental group experienced a systemic skin rash that resolved the same day, whereas the adverse events in the other group were mild and transient.

Conclusion

This trial demonstrated the feasibility of add-on effects and the safety of pharmacopuncture in patients with LSS. Further studies are warranted to evaluate the add-on effects of PPT in treating LSS.

Trial Registration

Clinical Research Information Service (CRIS), KCT0007229; registered on April 26, 2022.

Evaluation of differences in expression pattern of three isoforms of the transforming growth factor beta in patients with lumbosacral stenosis

The study investigates molecular changes in the lumbosacral (L/S) spine's yellow ligamentum flavum during degenerative stenosis, focusing on the role of transforming growth factor beta 1-3 (TGF-β-1-3). Sixty patients with degenerative stenosis and sixty control participants underwent molecular analysis using real-time quantitative reverse transcription reaction technique (RTqPCR), enzyme-linked immunosorbent assay (ELISA), Western blot, and immunohistochemical analysis (IHC). At the mRNA level, study samples showed reduced expression of TGF-β-1 and TGF-β-3, while TGF-β-2 increased by only 4%. Conversely, at the protein level, the study group exhibited significantly higher concentrations of TGF-β-1, TGF-β-2, and TGF-β-3 compared to controls. On the other hand, at the protein level, a statistically significant higher concentration of TGF-β-1 was observed (2139.33 pg/mL ± 2593.72 pg/mL vs. 252.45 pg/mL ± 83.89 pg/mL; p < 0.0001), TGF-β-2 (3104.34 pg/mL ± 1192.74 pg/mL vs. 258.86 pg/mL ± 82.98 pg/mL; p < 0.0001), TGF-β-3 (512.75 pg/mL ± 107.36 pg/mL vs. 55.06 pg/mL ± 9.83 pg/mL, p < 0.0001) in yellow ligaments obtained from patients of the study group compared to control samples. The study did not establish a significant correlation between TGF-β-1-3 concentrations and pain severity. The findings suggest that molecular therapy aimed at restoring the normal expression pattern of TGF-β-1-3 could be a promising strategy for treating degenerative stenosis of the L/S spine. The study underscores the potential therapeutic significance of addressing molecular changes at the TGF-β isoforms level for better understanding and managing degenerative spinal conditions.

Evaluation of the Concentration of Selected Elements in the Serum of Patients with Degenerative Stenosis of the Lumbosacral Spine

In humans, 23 elements have been shown to have biological activity. The purpose of this study was to evaluate the concentrations of iron (Fe), zinc (Zn), sodium (Na), potassium (K), magnesium (Mg), phosphorus (P), and calcium (Ca) in the serum of patients diagnosed with lumbar degenerative stenosis when compared to the concentrations of those elements in the serum of healthy volunteers. The study group consisted of 60 patients who were diagnosed with degenerative stenosis of the lumbosacral spine and who qualified for hemilaminectomy. The control group included 60 healthy volunteers without degenerative spinal stenosis. The clinical specimens studied had sera collected from both groups. The quantitative analysis of the selected elements revealed statistically significant (p < 0.05) lower concentrations of Zn (740 ± 110 µg/L vs. 880 ± 160 µg/L) and Mg (22,091 ± 4256 µg/L vs. 24,100 ± 4210 µg/L) in the serum of the patients from the study group when compared to the controls. By contrast, K (16,230 µg/L ± 1210 µg/L vs. 13,210 µg/L ± 1060 µg/L) and Fe (141.87 µg/L ± 11.22 µg/L vs. 109.1 µg/L ± 26.43 µg/L) levels were significantly higher in the study group compared to the controls (p < 0.05). No statistically significant changes were detected in the concentrations of the assessed micronutrients and macronutrients in both sexes in either the study group, the control group, or those based on body mass index (p > 0.05). In the serum samples from the study group, the strongest correlations were noted between the concentrations. In the study group, we showed a significant relationship between the levels of Fe/Zn (r = 0.41), Fe/Na (r = 0.41), Fe/P (r = 0.55), Zn/P (r = 0.68), Zn/K (r = 0.48), Zn/Ca (r = 0.94), Mg/Ca (r = 0.79), and Na/K (r = 0.67). We showed that only Mg concentration varied statistically significantly with the severity of pain (p < 0.05). These findings suggest that the assessment of Fe, Zn, Mg, and K concentrations can be helpful in predicting the onset of degenerative changes in the spine.

Effect and Safety of Combining Pharmacopuncture Therapy and Acupotomy in the Treatment of Patients with Degenerative Lumbar Spinal Stenosis: a Study Protocol for a Pragmatic, Assessor-Blinded, Randomized, Controlled Trial

Background

: Pharmacopuncture therapy and acupotomy are commonly used in combination for Conventional Korean Medicine Treatments (CKMT) for the treatment of patients with lumbar spinal stenosis (LSS). The aim of this study is to evaluate the effect and safety of combining pharmacopuncture therapy and acupotomy in the treatment of LSS.

Methods

: This study is designed as a pragmatic, assessor-blinded, randomized controlled trial with two parallel arms in a 1:1 ratio. A total of 104 participants diagnosed with LSS will be randomly assigned to an experimental group (pharmacopuncture therapy and acupotomy in addition to CKMT) or a control group (only CKMT). Patients in both groups will receive treatment two times weekly for 6 weeks. The primary outcome will be the mean change on the 100-mm visual analog scale (VAS) from the baseline to the end of the treatment (week 6). The secondary outcomes will include the mean change in the 100-mm VAS from baseline to week 10 and week 14, respectively. Proportion of patients who achieve the clinically important difference, Zurich Claudication Questionnaire, Roland-Morris disability questionnaire, self-reported maxium walking distance, EuroQol 5-dimension 5-level, and Patients' Global Impression of Change will also be assessed. Adverse events will be assessed at each visit. The outcomes will be measured for a total of 14 weeks, including a treatment period of 6 weeks and follow-up of 4, 8 weeks.

Discussion

: The results of this trial will confirm the effect and safety of combining pharmacopuncture therapy and acupotomy in the treatment of patients with LSS.

Machine Learning Predicts Decompression Levels for Lumbar Spinal Stenosis Using Canal Radiomic Features from Computed Tomography Myelography

BACKGROUND

The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The objective of this study was to develop machine learning (ML) classifiers that can predict decompression levels using computed tomography myelography (CTM) data from LSS patients.

METHODS

A total of 1095 lumbar levels from 219 patients were included in this study. The bony spinal canal in CTM images was manually delineated, and radiomic features were extracted. The extracted data were randomly divided into training and testing datasets (8:2). Six feature selection methods combined with 12 ML algorithms were employed, resulting in a total of 72 ML classifiers. The main evaluation indicator for all classifiers was the area under the curve of the receiver operating characteristic (ROC-AUC), with the precision-recall AUC (PR-AUC) serving as the secondary indicator. The prediction outcome of ML classifiers was decompression level or not.

RESULTS

The embedding linear support vector (embeddingLSVC) was the optimal feature selection method. The feature importance analysis revealed the top 5 important features of the 15 radiomic predictors, which included 2 texture features, 2 first-order intensity features, and 1 shape feature. Except for shape features, these features might be eye-discernible but hardly quantified. The top two ML classifiers were embeddingLSVC combined with support vector machine (EmbeddingLSVC_SVM) and embeddingLSVC combined with gradient boosting (EmbeddingLSVC_GradientBoost). These classifiers achieved ROC-AUCs over 0.90 and PR-AUCs over 0.80 in independent testing among the 72 classifiers. Further comparisons indicated that EmbeddingLSVC_SVM appeared to be the optimal classifier, demonstrating superior discrimination ability, slight advantages in the Brier scores on the calibration curve, and Net benefits on the Decision Curve Analysis.

CONCLUSIONS

ML successfully extracted valuable and interpretable radiomic features from the spinal canal using CTM images, and accurately predicted decompression levels for LSS patients. The EmbeddingLSVC_SVM classifier has the potential to assist surgical decision making in clinical practice, as it showed high discrimination, advantageous calibration, and competitive utility in selecting decompression levels in LSS patients using canal radiomic features from CTM.

Add-on Effect and Safety of Pharmacopuncture Therapy in the Treatment of Patients with Lumbar Spinal Stenosis

Background

Recently, Korean Medicine treatment with pharmacopuncture therapy (PPT) has been increasingly used in clinical practice to improve symptoms in patients with lumbar spinal stenosis (LSS). The aim of this study is to evaluate the effectiveness and safety of PPT in addition to conventional Korean Medicine treatment (CKMT) for the treatment of patients with LSS, compared with CKMT alone.

Methods

This study is designed as a pragmatic, randomized, two-armed, parallel, stratified (by sex), controlled pilot trial. Forty patients diagnosed with LSS will be randomly allocated to the PPT + CKMT group or the CKMT group. Patients in the two groups will receive treatment two times weekly for 5 weeks. The primary outcome will be the mean change in the 100-mm visual analog scale score from the baseline to the end of treatment (week 5). The secondary outcomes will include the clinically important difference, Zurich Claudication Questionnaire score, self-reported walking capacity, Modified-Modified Schober test, EuroQol 5-dimension 5-level questionnaire, and Patients' Global Impression of Change. Adverse events will be assessed at each visit.

Discussion

The results of this study will provide meaningful data to evaluate the add-on effect and safety of PPT in the medical care of patients with LSS.

Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review

Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.

Analysis of complications and unsatisfactory results of surgical treatment of degenerative lumbar spinal stenosis in the elderly patients

Background. The results of treatment of the elderly patients operated for spinal stenosis allow us to suggest that a cascade of degenerative changes in the spinal motion segments causes the formation of an adjacent level syndrome, pseudarthrosis, and in some cases – the instability in the fixing structure.The aim of the study. To determine the prognostic factors for the adjacent level syndrome in patients after decompressive and stabilizing spinal surgeries.Methods. We carried out a retrospective cohort study of the surgical treatment of 129 elderly patients (over 60 years of age) for the period from January 2018 to March 2022, who underwent surgery at the lumbosacral level of spine for degenerative spinal stenosis.Results. The outcomes of surgical treatment of 129 patients and the results of discriminant analysis of morphometric studies of computed tomography data indicate that the most significant indicators for the development of the adjacent level syndrome are the lordosis angle in the segment adjacent to the operated one (the mean value in the analyzed group is 12.87 ± 2.22°; in the control group – 11.92 ± 2.97°); the anterior height of the adjacent intervertebral disc (the mean value in the analyzed group is 12.70 ± 2.44 mm; in the control group – 11.46 ± 3.58 mm) and the difference of anterior and posterior disc heights at the adjacent level (the mean value in the analyzed group is 5.48 ± 2.84 mm; in the control group – 6.27 ± 2.71 mm).Conclusion. When analyzing the treatment outcomes of 129 elderly patients operated for degenerative spinal stenosis using instrumented spinal fusion, we revealed that in 16 patients, the adjacent level syndrome developed with an increase in the lordosis angle at the level adjacent to the operated segment. An increase in the anterior height of the adjacent intervertebral disc and the decrease in the difference of anterior and posterior disc heights at the adjacent level can be considered as unfavorable prognostic factors (p = 0.83).

The retrospective analysis of platelet-rich plasma and corticosteroid injection under epiduroscopic guidance for radiculopathy in operated or unoperated patients for lumbar disc herniation

Objectives: Epiduroscopy is a treatment method that can be applied to operated or non-operated patients with lumbar disc pathology. The aim of our study was to investigate and compare the efficacy of corticosteroid and platelet-rich plasma (PRP) therapy that we have injected in epidural and foraminal spaces under the guidance of epiduroscopy in the operated or unoperated patients with radicular pain.

Patients and methods: The retrospective study was conducted with 62 patients (40 females, 22 males; mean age: 48±12.3 years; range, 20 to 75 years) between January 2014 and September 2020. Of the patients, 32 were unoperated, whereas 30 were operated. All the patients had radicular pain. All the patients were evaluated by the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) at the start, on the 10th day, and at one and six months after the procedure by polyclinic control and by a phone call for their last follow-up.

Results: The VAS and ODI scores of patients treated with corticosteroid and PRP were decreased on the 10th day, at one and six months and the last follow-up, and this decrease was statistically significant.

Conclusion: Both PRP and corticosteroid injections were effective in pain scores during short-term and long-term follow-ups owing to the contribution of epiduroscopic intervention by allowing local administration of PRP or corticosteroids and analgesic agents as well as its mechanical adhesiolysis effect.

A short-term oral corticosteroid for refractory lumbar spinal stenosis: a double-blinded randomized placebo-controlled clinical trial

Although epidural corticosteroids have been evaluated for the lumbar spinal stenosis (LSS) as an alternative treatment, oral corticosteroids have not been considered as a possible option for the patients with constant pain who have resistant against routine treatments. Therefore, this study aimed to investigate the efficacy of the short-term, low-dose oral prednisolone for refractory LSS. In this double-blinded randomized placebo-controlled clinical trial, 100 participants with the refractory LSS were selected from the out-patient clinics; however, 7 of them excluded before randomization. The patients were randomly allocated into two groups with a 1:1 ratio: the intervention group that received 10 mg prednisolone per day for 1 week and the control group that received the exact placebo. The patients' severity of pain in terms of the numerical rating scale, ability to walk in meters, and Oswestry Disability Index (ODI) were assessed and then compared to the baseline after 2 months. The baseline variables were NS between these two groups. At the 2-month follow-up, the ability to walk in meters has increased and the severity of pain and ODI have decreased in both groups. Notably, except for the walking distance, none of the differences were statistically significant. Except for the significant change in walking distance between the groups, no other significant difference was observed in any variables when comparing the delta of each variable (after-before). One-week treatment with daily 10 mg oral prednisolone was not effective on the patients with refractory LSS in the short-term follow-up.

Priapism, a symptom of claudication of the cauda equina in spinal stenosis

Priapism is defined as a persistent penile erection in the absence of sexual arousal. This symptom has been documented in patients with spinal stenosis although it is considered a rare finding. The European Association of Urology guidelines on priapism [Salonia et al., 2014] list cauda equina syndrome and spinal stenosis as causative factors for ischemic priapism although the literature describing this phenomenon appears sparse. Priapism can be a rare symptom of lumbar spine stenosis/transient cauda equina compression. This presentation is complex and believed to be a parasympathetic mediated autonomic disorder. This article discusses the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. Greater awareness of this clinical finding may help clinicians in their clinical decision making. In patients with suspected cauda equina syndrome, subjective enquiry regarding the symptom priapism may add to the patients overall clinical picture.

Patient-Reported Outcomes Following Lumbar Decompression Surgery: A Review of 2699 Cases

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Despite numerous advances in the technology and techniques available to spinal surgeons, lumbar decompression remains the mainstay of degenerative lumbar spine surgery. It has proven efficacy in trials, but only limited evidence of advantage over conservative management in large scale systematic reviews. We collated data from a large surgically managed cohort to evaluate the patient-reported outcomes.

METHODS

We performed a retrospective analysis of a prospectively populated database. Patient demographics, surgical details, and patient outcomes (Spine Tango core outcome measures index [COMI]-Low Back) were collected for 2699 lumbar decompression surgeries.

RESULTS

Lumbar decompression was shown to be successful at improving leg pain (mean improvement in visual analogue scale [VAS] at 3 months = 4) and to a lesser extent, back pain (mean improvement in VAS at 3 months = 2.61). Mean improvement in COMI score was 3.15 for all-comers. Minimal clinically important improvement (MCID) in COMI score (-2 points) was achieved in 73% of patients by 2-year follow-up. Primary surgery was more effective than redo surgery: odds ratio 0.547 (95% CI 0.408-0.733, P < .001). The benefits across all outcomes were maintained for the 2-year follow-up period. Patients can be classified according to their outcome as "early responders"; achieving MCID by 3 months (61% primary vs 41% redo), "late responders"; achieving MCID by 2 years (15% vs 20%) or nonresponders (24% vs 39%).

CONCLUSIONS

Lumbar decompression is effective in improving quality of life in appropriately selected patients. Patient-reported outcome measures collected routinely and collated within a registry are a powerful tool for assessing the efficacy of lumbar spine interventions and allow accurate counseling of patients perioperatively.

Accurate prediction of lumbar microdecompression level with an automated MRI grading system

OBJECTIVE

Lumbar spine MRI interpretations have high variability reducing utility for surgical planning. This study evaluated a convolutional neural network (CNN) framework that generates automated MRI grading for its ability to predict the level that was surgically decompressed.

MATERIALS AND METHODS

Patients who had single-level decompression were retrospectively evaluated. Sagittal T2 images were processed by a CNN (SpineNet), which provided grading for the following: central canal stenosis, disc narrowing, disc degeneration, spondylolisthesis, upper/lower endplate morphologic changes, and upper/lower marrow changes. The grades were used to calculate an aggregate score. The variables and the aggregate score were analyzed for their ability to predict the surgical level. For each surgical level subgroup, the surgical level aggregate scores were compared with the non-surgical levels.

RESULTS

A total of 141 patients met the inclusion criteria (82 women, 59 men; mean age 64 years; age range 28-89 years). SpineNet did not identify central canal stenosis in 32 patients. Of the remaining 109, 96 (88%) patients had a decompression at the level of greatest stenosis. The higher stenotic grade was present only at the surgical level in 82/96 (85%) patients. The level with the highest aggregate score matched the surgical level in 103/141 (73%) patients and was unique to the surgical level in 91/103 (88%) patients. Overall, the highest aggregate score identified the surgical level in 91/141 (65%) patients. The aggregate MRI score mean was significantly higher for the L3-S1 surgical levels.

CONCLUSION

A previously developed CNN framework accurately predicts the level of microdecompression for degenerative spinal stenosis in most patients.

Does country of origin influence research outcomes in operative interventions for lumbar spinal stenosis?

INTRODUCTION

Bias undermines evidence-based decision making. To counter this, surgeons must be aware of biases that may influence studies' reported outcomes. Lumbar spinal stenosis often requires operative intervention, with multiple available surgical strategies. Our aim was to assess the role that country of origin plays in published surgical outcomes for lumbar spinal stenosis.

METHODS

We performed a search strategy of MEDLINE and EMBASE for all English language primary research papers evaluating operative interventions for lumbar spinal stenosis during the years 2010-2019 inclusive. Small case series and meta-analyses were excluded. Papers were assessed for outcome positivity and country of origin. Data analysis was conducted using GraphPad Prism statistical software.

RESULTS

A total of 487 papers met the inclusion criteria. Of these, 419 (86%) reported positive outcomes. Asian studies were the most likely to report positive outcomes, at 93% (220 of 236), followed by US studies at 89% (98 of 110). European studies had the lowest positive publication rate at 69% (84 of 121). Region of origin was an independent predictor of positive study outcome on multivariable analysis when controlling for different study designs and healthcare systems.

CONCLUSION

There is an association between country of origin and positive reported outcome in studies evaluating interventions for lumbar spinal stenosis. Clinicians should consider this when making management decisions based on published evidence.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Long-term effect of physical inactivity on thoracic and lumbar disc degeneration-an MRI-based analysis of 385 individuals from the general population

BACKGROUND CONTEXT

The correlation between physical inactivity, thoracolumbar disc degeneration, and back pain remains unclear.

PURPOSE

This study investigated the relationship between short- and long-term physical inactivity and degenerative changes of the thoracic and lumbar spine in a southern German cohort from the general population over a time period of 14 years.

STUDY DESIGN/SETTING

This study was designed as a cross-sectional case-control study, nested in a prospective cohort from the "Cooperative Health Research in the Region of Augsburg/Kooperative Gesundheitsforschung in der Region Augsburg" (KORA) study.

PATIENT SAMPLE

All participants in the population-based KORA study were assessed using a physical activity questionnaire to establish a baseline in 1999-2001 (exam 1), within an initial follow up questionnaire in 2006-2008 (exam 2), and a second follow-up questionnaire between 2013 and 2014 (exam 3). A subsample of this group (400 subjects) underwent full body MR scan performed on a 3T magnetic resonance imaging scanner current with exam 3.

OUTCOME MEASURE

Data regarding physical inactivity over a time period of 14 years and back pain, and quantification of thoracic and lumbar disc degeneration on magnetic resonance imaging.

METHODS

Quantification of thoracic and lumbar disc degeneration was performed using the Pfirrmann score. Physical activity was grouped as no physical activity, irregularly for 1 hour, regularly for 1 hour, or regularly for ≥2 hours. This was used to calculate another variable "physical inactivity," with the options of irregular activity ≤1 hour per week or regularly ≥1 hour. Physical labor, walking, and cycling activity were additionally investigated. Correlations between physical inactivity measurements and thoracic and lumbar disc degeneration were analyzed via linear regression models adjusted for age, sex, BMI, hypertension, diabetes, and back pain.

RESULTS

In total, 385 individuals (mean age: 56 years, SD ± 9.19; 58.2% male) were included in this study. Mean summed Pfirrmann score was 2.41 (SD ± 4.19) in the thoracic and 1.78 (SD ± 1.81) in the lumbar spine. The level of current exercise in our cohort varied with 113 (29.4%) subjects exercising regularly ≥2 hours per week, 118 (30.7%) regularly 1 hour per week, 57 (14%) irregularly for about 1 hour per week, and 97 (25.2%) stated not to exercise at exam 3. Disc degeneration was more apparent in those with irregular activity <1 hour compared to those with regular activity of ≥1 hour and more per week (p<.01) and in those with no activity compared to those with regular activity of ≥2 (p<.001) measured using exam 3. Less physical activity over a time period of 14 years correlated with an increase of disc degeneration of the thoracic and lumbar spine after adjustment for age, sex, BMI, hypertension and diabetes mellitus (p<.05). There was no statistically significant association between physical labor, walking activity, or cycling activity with disc degeneration. Additionally, no significant correlations between degree of disc degeneration (p=.990), degree of physical inactivity (p=.158), and back pain were observed.

CONCLUSION

Degree of physical inactivity as measured over a time period of 14 years demonstrated a strong correlation with disc degeneration of the thoracic and lumbar spine.

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.

Validation of the LOCOMO-25 and its minimum clinically important differences in domain scores for Chinese patients with low back pain and neck pain

BACKGROUND

The 25-question Geriatric Locomotive Function Scale (LOCOMO-25) was developed to assess any decline in mobility functions. This study aims to validate the LOCOMO-25 in Chinese patients with chronic low back pain and/or neck pain.

METHODS

Adult patients with chronic low back pain and/or neck pain completed the LOCOMO-25, SF-36, EQ-5D-5L, ODI, VAS and/or NDI. Internal consistency was assessed by Cronbach's alpha coefficient (α). Test-retest reliability was assessed by intra-class correlation coefficients. Construct validity was assessed by Spearman correlation tests against other outcome measures. Sensitivity to detect differences between groups was assessed by Mann-Whitney U or Kruskal-Wallis H test, where appropriate. Intergroup comparison was performed further in terms of domain scores and their changes at test-retest.

RESULTS

A total of 111 patients were consecutively recruited. LOCOMO-25 demonstrated excellent internal consistency (α = 0.915) and test-retest reliability (Intraclass correlation: 0.705 to 0.826). LOCOMO-25 was significantly correlated with all domains of SF-36, EQ-5D, ODI, NDI, and VAS (p < 0.01). It was found to be sensitive in differentiating between patients with neural compression (32.8 ± 16.9) and without (21.2 ± 12.7), with history of fall(s) within the previous one year (30.8 ± 16.0) and without (24.2 ± 15.1), requires assistive devices for ambulation (40.6 ± 21.6) or independent (23.6 ± 13.1) and various pain levels (mild: 17.2 ± 10.6; moderate: 23.5 ± 11.7; severe: 38.5 ± 16.5). Patients with neural compression scored significantly higher in the domain of pain and patients requiring assistive devices for ambulation scored significantly higher in the domains of ADL and social functions. The minimum detectable differences for various domains of the LOCOMO-25 score included pain (2.76), activities of daily living (6.07), social function (1.59), and mental health status (2.06).

CONCLUSIONS

LOCOMO-25 has been validated in Chinese patients with chronic low back and neck pain with satisfactory psychometric properties, and with individual domain minimum clinically important differences. There is adequate internal consistency, test-retest reliability, construct validity and sensitivity to detect differences between patients with/without neural compression, different ambulatory statuses and pain severity.

Risk factors for 90-day reoperation and readmission after lumbar surgery for lumbar spinal stenosis

OBJECTIVES

The objective of this study was to evaluate the incidence and risk factors for 90-day readmission and reoperation after elective surgery for lumbar spinal stenosis (LSS).

METHODS

The authors performed a retrospective consecutive cohort analysis of patients undergoing posterior lumbar decompression with or without fusion for LSS with claudication from January 2014 through December 2015.

RESULTS

Data were collected on 1592 consecutive patients. The mean age at surgery was 67.4 ± 10.1 years and 45% of patients were female. The 90-day reoperation rate was 4.7%, and 69.3% of the reoperations occurred within the first 30 days. The 90-day readmission rate was 7.2%. Multivariable analysis showed that postoperative development of a surgical site infection (SSI; odds ratio [OR] 14.09, 95% confidence interval [CI] 7.86–25.18), acute kidney injury (AKI; OR 6.76, 95% CI 2.39–19.57), and urinary tract infection (UTI; OR 3.96, 95% CI 2.43–6.37), as well as a history of congestive heart failure (CHF; OR 3.03, 95% CI 1.69–5.28), were significant risk factors for readmission within 90 days. Male sex (OR 0.60, 95% CI 0.38–0.92) was associated with decreased odds for readmission. With regards to reoperation, development of SSI (OR 25.06, 95% CI 13.54–46.51), sepsis (OR 7.63, 95% CI 1.52–40.59), UTI (OR 2.54, 95% CI 1.31–4.76), and increased length of stay (LOS; OR 1.25, 95% CI 1.17–1.33) were found to be significant risk factors. A subsequent analysis found that morbid obesity (OR 6.99), history of coronary artery disease (OR 2.263), increased duration of surgery (OR 1.004), and LOS (OR 1.07) were significant risk factors for developing an SSI.

CONCLUSIONS

Overall, this study found rates of 4.7% and 7.2% for reoperation and readmission, respectively, within 90 days: 30.7% of the reoperations and 44.7% of the readmissions occurred beyond the first 30 days. A diagnosis of SSI, AKI, UTI, and history of CHF were significant factors for readmission, while male sex was associated with decreased odds for readmission. A diagnosis of SSI, sepsis, UTI, and increased LOS were found to be significant predictors for reoperation. Understanding 90-day complication rates is imperative because there has been increased discussion and healthcare policy extending the global postoperative window to 90 days. Current literature supports a readmission rate of 3%–9% after spine surgery. However, this literature either is limited to a 30-day window or does not stratify between different types of spine surgeries.

ABBREVIATIONS

AKI = acute kidney injury; BPH = benign prostate hyperplasia; CAD = coronary artery disease; CHF = congestive heart failure; CI = confidence interval; CMS = Centers for Medicare and Medicaid Services; COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; EBL = estimated blood loss; LOS = length of stay; LSS = lumbar spinal stenosis; OR = odds ratio; POUR = postoperative urinary retention; SSI = surgical site infection; UTI = urinary tract infection.

Updated imaging does not affect revision rates in adults undergoing spine surgery for lumbar degenerative disease

OBJECTIVEDiagnostic workup for lumbar degenerative disc disease (DDD) includes imaging such as radiography, MRI, and/or CT myelography. If a patient has unsuccessful nonoperative treatment, the surgeon must then decide if obtaining updated images prior to surgery is warranted. The purpose of this study was to investigate whether the timing of preoperative neuroimaging altered clinical outcome, as reflected by the subsequent rate of revision surgery, in patients with degenerative lumbar spinal pathology.METHODSFrom the Health Care Service Corporation administrative claims database, adult patients (minimum age 55 years old) with lumbar DDD who underwent surgery including posterior lumbar decompression with and without fusion (1-2 levels) and at least 5 years of continuous coverage after the index surgery were identified. The chi-square test was used to determine differences in revision rates stratified by timing of each imaging procedure relative to the index procedure (< 6 months, 6-12 months, 12-24 months, or > 24 months).RESULTSOf 28,676 cases identified, 5128 (18%) had revision surgery within 5 years. The timing of preoperative MRI or plain radiography was not associated with revision surgery. Among the entire cohort, there was a lower incidence of revision surgery in patients who had a CT myelogram within 1 year prior to the index surgery (p = 0.017). This observation was strongest in patients undergoing decompression only (p = 0.002), but not significant in patients undergoing fusion (p = 0.845).CONCLUSIONSRoutine reimaging prior to surgery, simply because the existing MRI is 6-12 months old, may not be beneficial, at least as reflected in subsequent revision rates. The study also suggests that there may be a subset of patients for whom preoperative CT myelography reduces revision rates. This topic has important financial implications and deserves further study in a more granular data set.

Microscopic Anterior Neural Decompression Combined with Oblique Lumbar Interbody Fusion-A Technical Note

BACKGROUND

Minimally invasive oblique lumbar interbody fusion (OLIF) techniques generally rely on deformity correction to achieve indirect neural decompression. However, indirect neural decompression will not always be sufficient. Thus, a second procedure, such as posterior direct decompression, will be added for full decompression, increasing the surgical morbidity and healthcare costs. We have described a technique of direct anterior microscopic neural decompression combined with OLIF.

METHODS

We report our surgical technique of anterior lumbar neural microscopic decompression with OLIF with patients in the lateral position. We also report the cases of 3 patients treated from March 2018 to June 2018.

RESULTS

Three patients underwent anterior microscopic neural decompression combined with OLIF in the lateral position. All 3 patients achieved clinically and radiologically significant neural decompression and deformity correction. No perioperative complications developed.

CONCLUSION

Direct anterior microscopic neural decompression is feasible and safe in selected patients undergoing OLIF.

The modified transforaminal endoscopic technique in treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniations

Background

To develop a modified transforaminal endoscopic spine system (TESSYS^®) technique for treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation (ICFE-LDH), and evaluate the technical efficacy and safety.

Methods

Twenty-three patients with ICFE-LDH underwent the modified TESSYS technique were enrolled. Magnetic resonance imaging (MRI) was used to verify the reduction of herniated disc. Pre- and post-operative neurological functions were compared by visual analogue scale (VAS) score, Oswestry disability index (ODI) and the modified MacNab criteria. The technical safety was evaluated by surgical complications.

Results

MRI demonstrated reductions of disc herniations in 22 patients (95.7%) after surgeries. The VAS scores were significantly improved at 1 year follow-up (low back: P=0.001, lower limbs: P<0.001), as well as ODI scores (P<0.001). 22 patients had achieved excellent and good recovery postoperatively according to the modified MacNab criteria. One patient (4.3%) underwent a reoperation due to postoperative recurrence of disc herniation. Another patient complained postoperative causalgia in 8 weeks, the symptom alleviated after conservative treatment at 1 year follow-up (VAS: back, 3, lower limbs, 0; ODI: 20%). The incidence rate of surgical complication was 8.7%.

Conclusions

The modified TESSYS technique is a minimally-invasive, effective and safe surgery for treating ICFE-LDHs in selected patients.

Trends in isolated lumbar spinal stenosis surgery among working US adults aged 40-64 years, 2010-2014

OBJECTIVE Recommendations for the surgical treatment of isolated lumbar spinal stenosis (LSS) (i.e., in the absence of concomitant scoliosis or spondylolisthesis) are unclear. The aims of this study were to investigate trends in the surgical treatment of isolated LSS in US adults and determine implications for outcomes. METHODS The authors analyzed inpatient and outpatient claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database for 20,279 patients aged 40-64 years who underwent surgery for LSS between 2010 and 2014. Only patients with continuous 12-month insurance coverage after surgery were included. The rates of decompression with arthrodesis versus decompression only and of simple (1- or 2-level, single-approach) versus complex (> 2-level or combined-approach) arthrodesis were analyzed by year and geographic region. These trends were further analyzed with respect to complications, length of hospital stay, payments made to the hospital, and patient discharge status. Statistical significance was set at p < 0.05. RESULTS The proportion of patients who underwent decompression with arthrodesis compared with decompression only increased significantly and linearly from 2010 to 2014 (OR 1.08; 95% CI 1.06-1.10). Arthrodesis was more likely to be complex rather than simple with each subsequent year (OR 1.4; 95% CI 1.33-1.49). This trend was accompanied by an increased likelihood of postoperative complications (OR 1.11; 95% CI 1.02-1.21), higher costs (payments increased by a mean of US$1633 per year; 95% CI 1327-1939), and greater likelihood of being discharged to a skilled nursing facility as opposed to home (OR 1.11; 95% CI 1.03-1.20). The South and Midwest regions of the US had the highest proportions of patients undergoing arthrodesis (48% and 42%, respectively). The mean length of hospital stay did not change significantly (p = 0.324). CONCLUSIONS From 2010 to 2014, the proportion of adults undergoing decompression with arthrodesis versus decompression only for the treatment of LSS increased, especially in the South and Midwest regions of the US. A greater proportion of these fusions were complex and were associated with more complications, higher costs, and a greater likelihood of being discharged to a skilled nursing facility.

[Operative treatment of degenerative diseases of the lumbar spine]

BACKGROUND

Degenerative diseases of the lumbar spine and associated lower back pain represent a major epidemiological and health-related economic challenge. A distinction is made between specific and unspecific lower back pain. In specific lower back pain lumbar disc herniation and spinal canal stenosis with or without associated segment instability are among the most frequent pathologies. Diverse conservative and operative strategies for treatment of these diseases are available.

OBJECTIVES

The aim of this article is to present an overview of current data and an evidence-based assessment of the possible forms of treatment.

MATERIAL AND METHODS

An extensive literature search was carried out via Medline plus an additional evaluation of the authors' personal experiences.

RESULTS

Conservative and surgical treatment represent efficient treatment options for degenerative diseases of the lumbar spine. Surgical treatment of lumbar disc herniation shows slight advantages compared to conservative treatment consisting of faster recovery of neurological deficits and a faster restitution of pain control. Surgical decompression is superior to conservative measures for the treatment of spinal canal stenosis and degenerative spondylolisthesis. In this scenario conservative treatment represents an important supporting measure for surgical treatment in order to improve the mobility of patients and the outcome of surgical treatment.

CONCLUSION

The treatment of specific lower back pain due to degenerative lumbar pathologies represents an interdisciplinary challenge, requiring both conservative and surgical treatment strategies in a synergistic treatment concept in order to achieve the best results for patients.