Comparison of Effects of Nonoperative Treatment and Decompression Surgery on Risk of Patients with Lumbar Spinal Stenosis Falling: Evaluation with Functional Mobility Tests

Effects of Spinal Decompression and Segmental Spinal Instrumentation on Lower Limb Functionality in Patients with Spinal Osteoarthritis

Spinal osteoarthritis, a degenerative condition of the spine, significantly impairs quality of life, causing pain, stiffness, and limited mobility. Treatment primarily aims to improve functionality and quality of life. This study investigated the effects of lower back surgery (e.g., spinal decompression with vertebra stabilization) on upper-limb maximum strength, lower limb functionality, and quality of life in osteoarthritis patients. A total of 16 patients (♀ = 10 and ♂ = 6) patients from the orthopedic clinic who were diagnosed with osteoarthritis based on MRI and clinical symptoms underwent the surgery. Their handgrip strength, lower limb functionality (6 min walk test), and quality of life (Flanagan quality of life scale) were assessed before and after the surgery. A repeated measures ANOVA was conducted to assess differences in these metrics pre- and post-surgery across the entire patient cohort, as well as within gender-specific subgroups. A large positive effect was seen in the 6 min walk (p = 0.02, d = -0.83) test but not in the handgrip test or quality of life. However, female patients showed a trend towards better quality of life. The results of this study provide evidence for the effectiveness of surgery in the treatment of spinal osteoarthritis and underscore the need for personalized treatment approaches in the treatment of spinal osteoarthritis.

The relation of osteoporotic vertebral fractures and spine degeneration on the occurrence of complications: a systematic review

STUDY DESIGN

Systematic review.

PURPOSE

Osteoporotic vertebral fractures (OVFs) and degenerative spine conditions are age-related and associated with higher morbidity and mortality and greater health care costs. The relationship between OVFs and prevalent spine degeneration is rarely reported. The aim of this study was to systematically review current literature on the influence of preexisting degenerative spine conditions in patients with OVFs on the occurrence of complications during and after treatment.

METHODS

A systematic literature review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using Web of Science and MEDLINE. We considered English and German articles published from January 1990 to December 2022. The inclusion criteria were patients with OVFs and preexisting spinal degeneration with complications such as subsequent fractures, deformity, implant failure and surgical and general complications. The included studies were controlled trials, cohort studies, and case series.

RESULTS

Ten articles met the inclusion criteria (two prospective studies, seven retrospective studies and one case series). These were divided into two groups: studies on OVFs in patients with coexisting degenerative spine conditions (n = 5) and studies on OVFs following surgical treatment for degenerative spine conditions (n = 5). Three studies reported more complications in patients with OVFs and severe degeneration. One study stated the opposite. One study did not find any correlation. The remaining studies described complications narratively. Subsequent fractures were the most frequent complications.

CONCLUSION

OVFs in patients with preexisting spinal degeneration seem to cause more complications. In addition to subsequent fractures, other complications have rarely been examined. The presence of degenerative changes or undergoing surgical correction may increase the risk of subsequent fractures.

Impact of surgical treatment on lipid metabolism in patients with lumbar spinal disorders: Prospective observational study

PURPOSE

It is still unclear how lumbar spinal surgery affects the lipid metabolism of patients with lumbar spinal disorders (LSDs) such as lumbar spinal canal stenosis and lumbar disk herniation. The present study aimed to assess the impact of lumbar spinal surgery on lipid metabolism in patients with LSDs and clarify the factors associated with changes in visceral fat (VF) accumulation before and after lumbar spinal surgery.

METHODS

Consecutive patients with lumbar spinal surgery for LSDs were prospectively included. Abdominal computed tomography images and blood examination of the participants were evaluated before surgery and at 6 months and 1 year after surgery. The cross-sectional VF area (VFA) was measured at the level of the navel using computed tomography images. Blood examination items included triglycerides and high-density lipoprotein (HDL).

RESULTS

The study enrolled a total of 138 patients. Female patients with LSDs had significantly increased VFA and serum triglyceride levels after lumbar spinal surgery. On multivariable analysis, the group with > 100 cm2 of preoperative VFA and a postoperative decrease in VFA had a significantly worse preoperative walking ability based on the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (relative risk 2.1; 95% confidence intervals 1.1-4.1).

CONCLUSIONS

The present study demonstrated that patients with LSDs did not necessarily improve their lipid metabolism after lumbar spinal surgery. Instead, female patients with LSDs had significantly deteriorated lipid metabolism after lumbar spinal surgery. Finally, a worse preoperative walking ability was associated with the improvement in excess VF accumulation after lumbar spinal surgery.

Impact of spinal surgery on locomotive syndrome in patients with lumbar spinal stenosis in clinical decision limit stage 3: a retrospective study

BACKGROUND

Locomotive syndrome (LS) is characterized by reduced mobility. Clinical decision limit (CDL) stage 3 in LS indicates physical frailty. Lumbar spinal canal stenosis (LSS) is one of the causes of LS, for which lumbar surgery is considered to improve the CDL stage. This study aimed to investigate the efficacy of lumbar surgery and independent factors for improving the CDL stage in patients with LSS.

METHODS

This retrospective study was conducted at the Department of Orthopaedic Surgery at our University Hospital. A total of 157 patients aged ≥ 65 years with LSS underwent lumbar surgery. The 25-Question Geriatric Locomotive Function scale (GLFS-25) was used to test for LS, and the Timed Up and Go test (TUG) was used to evaluate functional ability. Lower limb pain was evaluated using a visual analog scale. Patients with at least one improvement in the CDL stage following lumbar surgery were included in the improvement group. Differences in lower limb pain intensity between the groups were evaluated using the Wilcoxon rank-sum test. The Spearman's rank correlation coefficient was used to determine correlations between Δ lower limb pain and Δ GLFS-25. Logistic regression analysis was used to identify factors associated with improvement in LS.

RESULTS

The proportion of patients with improved CDL stage was 45.1% (improvement/non-improvement: 32/39). Δ Lower limb pain was significantly reduced in the improvement group compared with that in the non-improvement group (51.0 [36.3-71.0] vs 40.0 [4.0-53.5]; p = 0.0107). Δ GLFS-25 was significantly correlated with Δ lower limb pain (r = 0.3774, p = 0.0031). Multiple logistic regression analysis revealed that TUG and age were significantly associated with improvement in LS (odds ratio, 1.22; 95% confidence interval: 1.07-1.47).

CONCLUSIONS

Lumbar surgery effectively improved the CDL stage in patients with LSS. In addition, TUG was an independent factor associated with improvement in the CDL.

Efficacy of surgical treatment on polypharmacy of elderly patients with lumbar spinal canal stenosis: retrospective exploratory research

BACKGROUND

Polypharmacy is a growing public health problem occurring in all healthcare settings worldwide. Elderly patients with lumbar spinal canal stenosis (LSS) who manifest low back and neuropathic pain and have a high frequency of comorbidity are predicted to take many drugs. However, no studies have reported polypharmacy in elderly patients with LSS. Thus, we aimed to review the polypharmacy among elderly LSS patients with elective surgeries and examine how the surgical treatment reduces the polypharmacy.

METHODS

We retrospectively enrolled all the patients aged ≥ 65 years who underwent spinal surgery for LSS between April 2020 and March 2021. The prescribed drugs of participants were directly checked by pharmacists in the outpatient department preoperatively and 6-month and 1-year postoperatively. The baseline characteristics were collected beside the patient-based outcomes including Roland-Morris Disability Questionnaire, Zurich Claudication Questionnaire, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The cutoff number of drugs for polypharmacy was defined as 6. The prescription drugs were divided into 9 categories: drugs for neuropsychiatric, cardiovascular, respiratory, digestive, endocrine metabolic, and urinary renal diseases; blood products; pain relief medication; and others.

RESULTS

A total of 102 cases were finally analyzed, with a follow-up rate of 78.0%. Of the participants, the preoperative polypharmacy prevalence was 66.7%. The number of drugs 6-month and 1-year postoperatively was significantly less than the preoperative one. The proportions of polypharmacy at 6 months and 1 year after surgery significantly decreased to 57.8% and 55.9%, respectively. When the prescribed drugs were divided into 9 categories, the number of drugs for pain relief and digestive diseases was significantly reduced after surgery. The multi-variable analysis revealed that a higher score in the psychological disorder of JOABPEQ was associated with 3 or more drugs decreased 1-year postoperatively (OR, 2.5; 95% CI: 1.0-6.1).

CONCLUSION

Polypharmacy prevalence was high among elderly LSS patients indicated for lumbar spinal surgery. Additionally, our data showed that lumbar spinal surgery was effective in reducing polypharmacy among elderly LSS patients. Finally, the multi-variable analysis indicated that better psychological condition was associated with the reduction of prescribed drugs after lumbar spinal surgery.

functional mobility tests for evaluation of functionalities in patients with adult spinal deformity

Study design

Retrospective cohort study.

Background

Current evaluation of patients with adult spinal deformity (ASD) is mainly based on radiographic parameters derived from X-rays. However, due to their static nature, X-rays fall short of assessing the dynamic functionalities including balance, gait, and the risk of falling. This study aimed to determine the functionalities of ASD patients by measuring functional mobility tests (FMTs) and compared the relationships between patient-reported outcomes (PROs) with FMTs and radiographic parameters to determine whether FMTs are useful evaluation tools for the evaluation of patients with ASD.

Methods

This age- and sex-matched case–control study included 66 patients with ASD and 66 patients with LSS, all of whom were scheduled to undergo spinal surgery. All patients were evaluated with four FMTs including alternate step test (AST), six-meter walk test (SMT), sit-to-stand test (STS), and timed up and go test (TUGT). Correlations of the PROs with FMTs and static radiographic parameters were analyzed.

Results

The baseline characteristics were not significantly different between the two groups. However, compared with patients with LSS, those with ASD showed significantly poorer performance on all four FMTs, spending significantly more time performing the SMT, STS, and TUGT (P = 0.046, 0.045, and 0.015, respectively). The results of the four FMTs were significantly correlated with the ODI (Oswestry Disability Index) scores only in the ASD group and not in the LSS group.

Conclusions

FMTs were appropriate tools for assessing the dynamic functionalities of patients with ASD. FMTs might play a bridging role between static radiographic parameters and subjective PROs when treating patients with ASD.

Handgrip Strength Correlated with Falling Risk in Patients with Degenerative Cervical Myelopathy

Background: Few studies have investigated associations between hand grip strength (HGS) and the surgical outcomes of degenerative cervical myelopathy (DCM). Methods: This study was designed as a prospective observational study of 203 patients who had undergone fusion surgery for DCM. We divided the patients according to sex and HGS differences. Clinical outcome parameters, including HGS, a fall diary and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, and sit-to-stand test) were measured preoperatively, at 3 months and 1 year after surgery. Results: Mean patient ages were 59.93 years in the male group and 67.33 years in the female group (p = 0.000; independent t-test). The mean HGS of both hands improved significantly at postoperative 3 months and 1 year in all patients (p = 0.000 for both; ANOVA). In male patients, preoperative risk of falls was negatively correlated with HGS (p = 0.000). In female patients, pre- and postoperative risk of falls were correlated negatively with HGS (p = 0.000). The postoperative incidence of falls decreased in both groups (p = 0.000) Conclusions: Postoperative HGS in patients with DCM is correlated with postoperative falls and functional outcome differently, when comparing male and female patients, for predicting favorable outcomes and neurologic deficit recovery after surgery in DCM patients.

Preoperative low muscle mass is a predictor of falls within 12 months of surgery in patients with lumbar spinal stenosis

BACKGROUND

Patients with lumbar spinal stenosis (LSS) may be at high risk of falls due to various factors. No effective fall risk assessments or fall prevention measures have been performed for patients with LSS because only a few studies have evaluated falls in these patients. This study aimed to evaluate the incidence and preoperative predictors of falls within 12 months of surgery in patients with LSS.

METHODS

In this prospective study of 82 consecutive preoperative patients with LSS, preoperative demographic data, previous fall history, leg pain, low back pain, Japanese Orthopaedic Association (JOA) score, Hospital Anxiety and Depression Scale (HADS) scores, lower extremity muscle strength, walking speed, grip strength, and muscle mass were assessed at baseline. Falls were assessed at 3, 6, 9, and 12 months after surgery. Participants were categorized as fallers and non-fallers and baseline variables were compared. Binomial logistic regression was used to identify predictors of falls within 12 months of surgery.

RESULTS

Seventy-four patients (90.2%) completed the 12-month follow-up after surgery, of whom 24 patients (32.4%) experienced falls. A higher proportion of fallers were female and had a history of falls compared to non-fallers. Fallers had a significantly lower JOA score and a higher HADS-depression score compared to non-fallers. Fallers had significantly lower tibialis anterior muscle strength, gait speed, grip strength, and skeletal muscle mass index. Fallers had a higher prevalence of low muscle mass compared with non-fallers. The presence of low muscle mass was significantly predictive of falls within 12 months of surgery (odds ratio, 4.46; 95% confidence interval, 1.02-19.63).

CONCLUSIONS

Patients with LSS have a high incidence of falls after surgery and preoperative low muscle mass may be a predictor of postoperative falls.

Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review

Patients with lumbar spinal stenosis may exhibit symptoms such as back pain, radiating pain, and neurogenic claudication. Although long-term outcome of treatments manifests similar results for both nonsurgical and surgical treatments, positive effects such as short-term improvement in symptoms and decreased fall risk may be expected with surgery. Surgical treatment is basically decompression, and a combination of treatments can be added depending on the degree of decompression and the accompanying instability. Recently, minimally invasive surgery has been found to result in excellent outcomes in the treatment of lumbar spinal stenosis. Therefore, better treatment effects can be anticipated with an approach aimed at understanding the overall pathophysiology and treatment methods of lumbar spinal stenosis.

Lumbar Spinal Canal Stenosis from the Perspective of Locomotive Syndrome and Metabolic Syndrome: A Narrative Review

Patients with lumbar spinal canal stenosis (LSS) have impaired activities of daily living because of pain or motor paralysis, but no effective preventive treatment is currently available. The number of patients with LSS is predicted to continually increase as the average age of the global population increases. To provide a conceptual framework for improving healthy life expectancy, the Japanese Orthopaedic Association introduced the concept of locomotive syndrome, to which LSS is related. Ours and other studies have shown that LSS exacerbates locomotive syndrome and that surgical treatment is one method for improving it. Furthermore, we propose that the two-step test, a locomotive syndrome risk test, is effective for assessing the risk for falls and severity of LSS. Meanwhile, lumbar spinal epidural lipomatosis (LSEL), which is a manifestation of LSS, has been shown to be related to metabolic syndrome. Previous studies have suggested that the whole LSS can be also associated with metabolic syndrome. Although locomotive syndrome is very different from metabolic syndrome, which involves lipid metabolism, these two syndromes overlap, such as in LSS. Conducting research on LSS from the perspectives of both locomotive syndrome and metabolic syndrome may lead to novel methods for prevention and treatment of LSS and, conversely, may yield clues for resolving symptoms of the two syndromes. This review provides an overview of LSS from the perspective of locomotive syndrome and metabolic syndrome, along with findings from our research group.

Lumbar spinal surgery improves locomotive syndrome in elderly patients with lumbar spinal canal stenosis: A multicenter prospective study

BACKGROUND

Owing to musculoskeletal dysfunction, locomotive syndrome elevates the risk of requiring nursing care. Among degenerative musculoskeletal disorders, lumbar spinal canal stenosis (LSS) associates with locomotive syndrome; however, whether lumbar spinal surgery for LSS improves locomotive syndrome remains unclear. Hence, this study aimed to identify the efficacy of lumbar spinal surgery on locomotive syndrome among elderly patients with LSS.

METHODS

We prospectively collected the clinical data from multiple institutions of patients (age >65 years) who underwent lumbar spinal surgery. Patients were examined for the locomotive syndrome risk test, including the stand-up Test, the two-step Test, and the 25-question risk assessment, 1-day preoperatively and 6-month and 1-year postoperatively. Using a logistic regression model, we identified factors associated with improvement of locomotive syndrome in the total assessment.

RESULTS

Overall, we examined the data of 166 patients in this study. Upon converting each score of three tests to the stage of locomotive syndrome, the two-step test and the 25-question risk assessment revealed marked improvement in the postoperative distribution of stages. However, the stand-up test revealed a comparable distribution of stages pre- and postoperatively. In the total assessment, the postoperative distribution of stages was significantly improved than that preoperatively. The multivariable analysis revealed that failed back surgery syndrome [odds ratio (OR), 0.2; 95% confidence interval (CI): 0.04-1.05; P = 0.057)] and preoperative stage of 2 in stand-up test (OR, 0.2; 95% CI: 0.05-1.02; P = 0.054) tended to have inverse association with postoperative improvement of locomotive syndrome in the total assessment.

CONCLUSIONS

Lumbar spinal surgery improved the stage of locomotive syndrome among elderly patients with LSS. This study suggests that lumbar spinal surgery for LSS could be beneficial in alleviating locomotive syndrome.

Stride length of elderly patients with lumbar spinal stenosis: Multi-center study using the Two-Step test

BACKGROUND

Short stride length is one of clinical symptoms associated with lumbar spinal stenosis (LSS). Short stride is a risk factor for falls; therefore, identification of factors associated with short stride is critical for fall prevention in LSS patients. Although the Two-Step test can conveniently assess maximal stride length, it has not become widely used; therefore, its data are limited. We identified the potential factors associated with short stride of elderly LSS patients using Two-Step test.

METHODS

Clinical data of patients aged >65 years who planned to undergo surgery for LSS were prospectively collected at multiple institutions. Patients were assessed with the Two-Step test and Timed Up-and-Go Test prior to surgery; 357 consecutive patients were enrolled. We determined the cut-off value of the Two-Step test score for short stride, referring to the Timed Up-and-Go Test score of 13.5 s, used to indicate high risk of falls in elderly individuals. Logistic regression model was constructed to identify factors associated with short stride.

RESULTS

The Two-Step test score showed moderate-to-strong inverse correlation with that of Timed Up-and-Go Test (r = -0.65, p < 0.001). Using the tentative Two-Step test cut-off value (0.93) for short stride, multivariable analysis showed that age ≥80 years (OR = 2.3, 95% CI:1.1-4.8), a score of <60 for lumbar function in Japanese Orthopedic Association Back Pain Evaluation Questionnaire (OR = 2.7, 95% CI:1.5-4.7), motor deficit (OR = 2.7, 95% CI:1.2-6.1), and sagittal vertical axis ≥50 mm (OR = 2.1, 95% CI:1.2-3.5) were factors significantly associated with short stride in elderly patients with LSS.

CONCLUSIONS

Using the Two-Step test, we found that 80 years old and over, lumbar dysfunction, motor deficit of the lower extremities, and forward-bent posture were associated with short stride in LSS patients. Therefore, elderly LSS patients with these conditions may have a higher risk for falls.

Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature

BACKGROUND CONTEXT

The accurate determination of a patient's functional status is necessary for therapeutic decision-making and to critically appraise treatment efficacy. Current subjective patient-reported outcome measure (PROM)-based assessments have limitations and can be complimented by objective measures of function.

PURPOSE

To systematically review the literature and provide an overview on the available objective measures of function for patients with degenerative diseases of the lumbar spine.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two reviewers independently searched the PubMed, Web of Science, EMBASE, and SCOPUS databases for permutations of the words "objective," "assessment," "function," "lumbar," and "spine" including articles on human subjects with degenerative diseases of the lumbar spine that reported on objective measures of function, published until September 2018. Risk of bias was not assessed. No funding was received. The authors report no conflicts of interest.

RESULTS

Of 2,389 identified articles, 82 were included in the final analysis. There was a significant increase of 0.12 per year in the number of publications dealing with objective measures of function since 1989 (95% CI 0.08-0.16, p<.001). Some publications studied multiple diagnoses and objective measures. The United States was the leading nation in terms of scientific output for objective outcome measures (n=21; 25.6%), followed by Switzerland (n=17; 20.7%), Canada, Germany, and the United Kingdom (each n=6; 7.3%). Our search revealed 21 different types of objective measures, predominantly applied to patients with lumbar spinal stenosis (n=67 publications; 81.7%), chronic/unspecific low back pain (n=28; 34.2%) and lumbar disc herniation (n=22; 26.8%). The Timed-Up-and-Go test was the most frequently applied measure (n=26 publications; 31.7%; cumulative number of reported subjects: 5,181), followed by the Motorized Treadmill Test (n=25 publications; 30.5%, 1,499 subjects) and with each n=9 publications (11.0%) the Five-Repetition Sit-To-Stand test (955 subjects), as well as accelerometry analyses (336 subjects). The reliability and validity of many of the less-applied objective measures was uncertain. There was profound heterogeneity in their application and interpretation of results.

CONCLUSIONS

Clinical studies on patients with lumbar degenerative diseases increasingly employ objective measures of function, which offer high potential for improving the quality of outcome measurement in patient-care and research. This review provides an overview on available options. Our findings call for an agreement and standardization in terms of test selection, conduction and analysis to facilitate comparison of results across cohorts.

PROSPERO REGISTRATION NUMBER

CRD42019122622.

Objective functional assessment using the “Timed Up and Go” test in patients with lumbar spinal stenosis

OBJECTIVE

Patient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the “Timed Up and Go” (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).

METHODS

A prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.

RESULTS

Sixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.

CONCLUSIONS

The TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.

Lumbar spinal canal stenosis leads to locomotive syndrome in elderly patients

BACKGROUND

Locomotive syndrome is a condition in which the ability to lead a normal life is restricted owing to a dysfunction in one or more of the parts of the musculoskeletal system. Although lumbar spinal canal stenosis (LSS) is considered to cause locomotive syndrome, a detailed assessment of the association between two pathologies has not yet been reported.

METHODS

The clinical data of patients aged > 65 years old who planned to undergo surgery for LSS at multiple institutions were prospectively collected from April 2016 to August 2017. A total of 200 participants comprising 120 men and 80 women were enrolled in this study. Association of severity of LSS evaluated by Zurich Claudication Questionnaire scores with three locomotive syndrome risk tests (Stand-up Test, the Two-step Test, and a 25-question risk assessment) and Timed Up-and-Go Test were evaluated.

RESULTS

In the total assessment of locomotive syndrome, 96.5% of the participants were diagnosed as grade 2, and the remaining 3.5% were diagnosed as grade 1. When the participants were divided into 3 groups according to the LSS severity, the scores of all locomotive syndrome risk tests were significantly worse with increasing LSS severity. Logistic regression analysis revealed that LSS severity was positively correlated with the risk level of locomotive syndrome evaluated by the Two-step Test (OR = 3.45, CI = 1.33-8.96).

CONCLUSIONS

All LSS patients with surgical indications were diagnosed as having locomotive syndrome. In addition, our results indicated that LSS severity is potentially associated with the progression of locomotive syndrome. The treatment of LSS may be beneficial in alleviating the risk for locomotive syndrome.

Effect of Sagittal Balance on Risk of Falling after Lateral Lumbar Interbody Fusion Surgery Combined with Posterior Surgery

PURPOSE

To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach.

MATERIALS AND METHODS

From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes.

RESULTS

The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016).

CONCLUSION

Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

Surgical Outcome Predictor in Degenerative Lumbar Spinal Disease Based on Health Related Quality of Life Using Euro-Quality 5 Dimensions Analysis

PURPOSE

We aim to introduce the predictive value of a quantitatively described formula model in a multicenter prospective analysis using the EuroQol-5 dimensions (EQ-5D) health scale to anticipate postoperative improvement in patients with degenerative lumbar spine disease (DLSD).

MATERIALS AND METHODS

Quality of life was evaluated in 376 patients from 17 tertiary hospitals before and after spinal decompression and fusion surgery. The five items of the EQ-5D, mobility (M), self-care (S), usual activities (A), pain/discomfort (P), and anxiety/depression (D), were checked as level 1, 2, or 3, with 3 being the worst. A minimal significant change in the calculated EQ-5D (cEQ-5D) was set as 0.05. Logistic regression analysis was performed to predict the highest successful outcome (cEQ-5D improvement after operation >0.05) with the given sets of 5 items of the EQ-5D.

RESULTS

In the cEQ-5D analysis, among patients with a formula score of S+A+2×P+D≤8, 18/68 (27%) showed significant improvement in the cEQ-5D at 1 year postoperatively (p<0.05). However, in patients with a formula score of ≥9, 265/308 (86%) demonstrated significant improvements in the cEQ-5D at 1 year postoperatively (p<0.05).

CONCLUSION

We suggest that S+A+2×P+D≥9 in the EQ-5D can quantitatively describe the better surgical outcome predictors for DLSD. With a definite DLSD lesion confirmed by an imaging study, patients who meet the formula scores of 9 or over and have refractory symptoms to non-operative treatment could be better surgical candidates resulting in satisfactory surgical outcomes of over 86%, than those who scored 8 or lower.

Spinal sagittal balance status affects postoperative actual falls and quality of life after decompression and fusion in-situ surgery in patients with lumbar spinal stenosis

OBJECTIVES

It has been reported that good spinal sagittal alignment reduces the risk of fall and positive sagittal balance is the radiographic parameter that is most highly correlated with adverse health outcomes. However, no reports have demonstrated a change in risk of falling in patients with lumbar spinal stenosis (LSS) according to sagittal balance status.

PATIENTS AND METHODS

From September 2013 to October 2014, 141 patients who underwent lumbar spine surgery, including decompression and fusion in-situ for LSS, were enrolled in this study. Based on sagittal balance status, patients were divided into sagittal balance (SB) and sagittal imbalance (SI) groups. Four functional mobility tests were used to evaluate the risk of falling, and a fall diary, Oswestry disability index (ODI), and the Euro-QoL 5D(EQ-5D) visual analogue scale (VAS) were utilized to assess clinical improvement.

RESULTS

The mean patient age was 70.1 years in the SB group (N=46) and 70.9 years in the SI group (N=95) (not significant). The mean C7PL was 7.9mm in the SB group and 66.1mm in the SI group preoperatively (p<0.05). Among the four functional tests, only postoperative SMT and STS improved significantly in the SB group (p<0.05). Patients in the SI group showed significantly improved scores for all four functional tests during postoperative follow-up (p<0.05), but their performance was still worse than patients in the SB group. Average number of falls per individual during the follow-up period was 1.1±2.5 in the SB group and 1.9±3.2 in the SI group (p<0.05). There was a significant difference in the distribution of non-fallers and fallers (single and multiple fallers) between the two groups postoperatively(p<0.05). ODI and the EQ-5D VAS showed greater improvement in the SB group than the SI group. Multiple regression analysis revealed that sagittal balance during follow-up significantly affected ODI, EQ-VAS, functional mobility tests. (p<0.05).

CONCLUSION

Therefore, when fusion surgery is planned in patients with LSS, careful consideration of sagittal balance status might be important to attain better surgical and functional outcomes and decrease the incidence of actual falls after surgical treatment.