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Nurmukhametov R, Encarnacion Ramirez MDJ, Dosanov M, Medetbek A, Kudryakov S, Wisam Alsaed L, Chmutin G, Reyes Soto G, Ntalaja Mukengeshay J, Mpoyi Chérubin T, Nikolenko V, Gushcha A, Luzzi S, Rosario Rosario A, Ovalle CS, Valenzuela Mateo K, Lafuente Baraza J, Roa Montes de Oca JC, Rangel CC, Sharif S. Quantifying Lumbar Foraminal Volumetric Dimensions: Normative Data and Implications for Stenosis-Part 2 of a Comprehensive Series. Med Sci (Basel) 2024; 12:34. [PMID: 39051380 PMCID: PMC11270341 DOI: 10.3390/medsci12030034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/05/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Lumbar foraminal stenosis (LFS) occurs primarily due to degenerative changes in older adults, affecting the spinal foramina and leading to nerve compression. Characterized by pain, numbness, and muscle weakness, LFS arises from structural changes in discs, joints, and ligaments, further complicated by factors like inflammation and spondylolisthesis. Diagnosis combines patient history, physical examination, and imaging, while management ranges from conservative treatment to surgical intervention, underscoring the need for a tailored approach. MATERIALS AND METHODS This multicenter study, conducted over six years at a tertiary hospital, analyzed the volumetric dimensions of lumbar foramina and their correlation with nerve structures in 500 patients without lumbar pathology. Utilizing high-resolution MRI with a standardized imaging protocol, eight experienced researchers independently reviewed the images for accurate measurements. The study emphasized quality control through the calibration of measurement tools, double data entry, validation checks, and comprehensive training for researchers. To ensure reliability, interobserver and intraobserver agreements were analyzed, with statistical significance determined by kappa statistics and the Student's t-test. Efforts to minimize bias included blinding observers to patient information and employing broad inclusion criteria to mitigate referral and selection biases. The methodology and findings aim to enhance the understanding of normal lumbar foramina anatomy and its implications for diagnosing and treating lumbar conditions. RESULTS The study's volumetric analysis of lumbar foramina in 500 patients showed a progressive increase in foraminal volume from the L1/L2 to the L5/S1 levels, with significant enlargement at L5/S1 indicating anatomical and biomechanical complexity in the lumbar spine. Lateral asymmetry suggested further exploration. High interobserver and intraobserver agreement levels (ICC values of 0.91 and 0.95, respectively) demonstrated the reliability and reproducibility of measurements. The patient cohort comprised 58% males and 42% females, highlighting a balanced gender distribution. These findings underscore the importance of understanding foraminal volume variations for lumbar spinal health and pathology. CONCLUSION Our study significantly advances spinal research by quantifying lumbar foraminal volumes, revealing a clear increase from the L1/L2 to the L5/S1 levels, indicative of the spine's adaptation to biomechanical stresses. This provides clinicians with a precise tool to differentiate between pathological narrowing and normal variations, enhancing the detection and treatment of lumbar foraminal stenosis. Despite limitations like its cross-sectional design, the strong agreement in measurements underscores the method's reliability, encouraging future research to further explore these findings' clinical implications.
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Affiliation(s)
- Renat Nurmukhametov
- 2nd National Clinical Centre, Federal State Budgetary Research Institution, Russian Research Center of Surgery Named after Academician B.V. Petrovsky, 109240 Moscow, Russia; (R.N.); (M.D.); (A.M.); (S.K.)
- Department of Neurosurgery, Russian People’s Friendship University, 121359 Moscow, Russia; (L.W.A.); (G.C.)
| | | | - Medet Dosanov
- 2nd National Clinical Centre, Federal State Budgetary Research Institution, Russian Research Center of Surgery Named after Academician B.V. Petrovsky, 109240 Moscow, Russia; (R.N.); (M.D.); (A.M.); (S.K.)
| | - Abakirov Medetbek
- 2nd National Clinical Centre, Federal State Budgetary Research Institution, Russian Research Center of Surgery Named after Academician B.V. Petrovsky, 109240 Moscow, Russia; (R.N.); (M.D.); (A.M.); (S.K.)
| | - Stepan Kudryakov
- 2nd National Clinical Centre, Federal State Budgetary Research Institution, Russian Research Center of Surgery Named after Academician B.V. Petrovsky, 109240 Moscow, Russia; (R.N.); (M.D.); (A.M.); (S.K.)
| | - Laith Wisam Alsaed
- Department of Neurosurgery, Russian People’s Friendship University, 121359 Moscow, Russia; (L.W.A.); (G.C.)
| | - Gennady Chmutin
- Department of Neurosurgery, Russian People’s Friendship University, 121359 Moscow, Russia; (L.W.A.); (G.C.)
| | - Gervith Reyes Soto
- Department of Head and Neck, Unidad de Neurociencias, Instituto Nacional de Cancerología, Mexico City 110411, Mexico;
| | - Jeff Ntalaja Mukengeshay
- Neurosurgery Departament, Clinique Ngaliema, Kinshasa 3089, Democratic Republic of the Congo; (J.N.M.); (T.M.C.)
| | - Tshiunza Mpoyi Chérubin
- Neurosurgery Departament, Clinique Ngaliema, Kinshasa 3089, Democratic Republic of the Congo; (J.N.M.); (T.M.C.)
| | - Vladimir Nikolenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia;
| | - Artem Gushcha
- Department of Neurosurgery, Research Center of Neurology, 125367 Moscow, Russia
| | - Sabino Luzzi
- Department of Neurosurgery, University of Pavia, 27100 Pavia, Italy;
| | | | - Carlos Salvador Ovalle
- Department of Neurosurgery, National University of Mexico Hospital General, Durango 87106, Mexico;
| | | | - Jesus Lafuente Baraza
- Spine Center Hospital del Mar, Sagrat Cor University Hospital, 08029 Barcelona, Spain;
| | - Juan Carlos Roa Montes de Oca
- Deparment of Neurosurgery, Complejo Asistencial Universitario de Salamanca, University of Salamanca, 37008 Salamanca, Spain;
| | - Carlos Castillo Rangel
- Department of Neurosurgery, Servicio of the 1ro de Octubre Hospital of the Instituto de Seguridad Servicios Sociales de los Trabajadores del Estado, Mexico City 07760, Mexico;
| | - Salman Sharif
- Department of Neurosurgery, Liaqat National Hospital and Medical School, Stadium Road, Karachi 74800, Pakistan;
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Heard JC, Lee Y, Ezeonu T, Lambrechts MJ, Issa TZ, Yalla GR, Tran K, Singh A, Purtill C, Somers S, Becsey A, Canseco JA, Kurd MF, Kaye ID, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Does the Severity of Foraminal Stenosis Impact Outcomes of Lumbar Decompression Surgery? World Neurosurg 2023; 179:e296-e304. [PMID: 37633493 DOI: 10.1016/j.wneu.2023.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE To establish the relationship between the magnitude of foraminal stenosis and 1) improvement in patient-reported outcomes, 2) improvement in motor function after lumbar decompression surgery, and 3) difference in surgical outcomes. METHODS Patients who underwent one-level posterior lumbar decompression for radiculopathy were retrospectively identified. Patient demographics and surgical characteristics were collected through a query search and manual chart review of the electronic medical records. Foraminal stenosis was determined on magnetic resonance imaging and graded using Lee et al.'s validated methodology as none, mild, moderate, or severe. Surgical outcomes, motor function, and patient-reported outcome measures (PROMs) were compared based on the amount of stenosis (mild vs. moderate vs. severe). Bivariant and multivariant analyses were performed. RESULTS Severe stenosis demonstrated more 90-day readmissions (0.00% vs. 0.00% vs. 8.57%, respectively, P = 0.019), though this effect did not remain significant on multivariate analysis (P = 0.068). There was no association between stenosis severity and the degree of functional impairment or PROMs preoperatively. Patients with moderate or severe preoperative foraminal stenosis showed improvement in all PROMs after surgery (P < 0.05) except the mental component of the Short Form 12 survey. Notably, central stenosis grade was insignificantly different between groups (P = 0.358). Multivariable logistic regression analysis did not identify any significant independent predictors of surgical outcomes or changes in PROMs. CONCLUSIONS We demonstrated that regardless of foraminal stenosis severity preoperatively, patients have a similar improvement in PROMs, surgical outcomes, and restoration of motor function after lumbar decompression surgery for radiculopathy.
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Affiliation(s)
- Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Teeto Ezeonu
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Goutham R Yalla
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Khoa Tran
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Akash Singh
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Caroline Purtill
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sydney Somers
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander Becsey
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian D Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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The Influence of Rheumatoid Arthritis on Higher Reoperation Rates over Time Following Lumbar Spinal Fusion-A Nationwide Cohort Study. J Clin Med 2022; 11:jcm11102788. [PMID: 35628915 PMCID: PMC9145603 DOI: 10.3390/jcm11102788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022] Open
Abstract
This study aimed to compare the rates of reoperation over time following first lumbar fusion in rheumatoid arthritis (RA) patients and non-RA patients. This study was conducted using Korean Health Insurance Review and Assessment (HIRA) data. We identified the RA group as 2239 patients who underwent their first lumbar fusion with RA and the control group as 11,195 patients without RA. This reflects a ratio of 1:5, and the participants were matched by sex, age, and index surgery date. The index dates were between 2012 and 2013. When comparing the rate of patients undergoing reoperation, the adjusted HR was 1.31 (95% CI: 1.10−1.6) in the RA group (p = 0.002). In terms of the three time intervals, the values in the time frames of <3 months and 3 months−1 year were not statistically significant. However, at 1 year post-surgery, there was a higher risk of reoperation in the RA group, as demonstrated by the Kaplan−Meier cumulative event analysis. This higher risk of reoperation continued to increase throughout 5 years of follow-up, after which it was stable until the last follow-up at 7 years. This population-based cohort study showed that the RA patients had a 1.31 times higher risk of reoperation following lumbar fusion than did the controls. This difference was more pronounced at 1 year post-surgery.
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Abstract
STUDY DESIGN Narrative review. OBJECTIVE To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited. METHODS Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated. RESULTS The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine. CONCLUSIONS Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.
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Affiliation(s)
- Peter Joo
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Laurence Ge
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Addisu Mesfin
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA,Addisu Mesfin, Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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The Relationship Between Demographic Characteristics and Noninflammatory Complaints in Rheumatoid Arthritis Patients on Remission. J Clin Rheumatol 2019; 26:255-259. [PMID: 31136414 DOI: 10.1097/rhu.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the noninflammatory complaints in rheumatoid arthritis (RA) patients on remission and the relationship between these complaints and disease characteristics. METHODS This is a medical records review study of 103 RA patients who sustained a remission period for at least 6 months. Clinical features and demographic characteristics of patients, such as laboratory parameters, current number of sensitive and swollen joints, pain level and Patient Global Assessment, previously used medications, and modified Health Assessment Questionnaire, were carefully recorded. Patients were divided into 2 groups according to the presence of noninflammatory complaints as patients with or without noninflammatory complaints (group 1, n = 56; group 2, n = 47, respectively). RESULTS The most common complaints with a decreasing frequency were as follows: low back pain (n = 13 [23.2%]), degenerative knee pain (n = 11 [19.6%]), and widespread body pain due to fibromyalgia (n = 7 [12.5%]). The mean age and age at diagnosis were higher in group 1 than in those in group 2 (p = 0.039, and p = 0.014, respectively). CONCLUSIONS Noninflammatory complaints can be observed in about 50% of RA patients on remission. These complaints were more common in elderly patients with old-age disease onset. Therefore, while evaluating and treating this patient population, noninflammatory complaints and disease-specific parameters should be considered carefully in order to fully improve the clinical outcomes.
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Mitsuyama T, Kubota M, Yuzurihara M, Mizuno M, Hashimoto R, Ando R, Okada Y. The pitfalls in surgical management of lumbar canal stenosis associated with rheumatoid arthritis. Neurol Med Chir (Tokyo) 2013; 53:853-60. [PMID: 24140780 PMCID: PMC4508732 DOI: 10.2176/nmc.oa2012-0299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
There have been few clinical studies in the area of cervical spine that focused on surgery for treating degenerative lumbar disease in patients with rheumatoid arthritis (RA). High rates of wound complications and instrumentation failure have been reported more for RA than for non-RA patients, although clinical outcomes are similar between the two groups. Lumbar canal stenosis in RA is caused not only by degeneration but also by RA-related spondylitis, which includes facet arthritis and inflammation around the vertebral endplate. The pitfalls in surgical management of lumbar canal stenosis in RA patients are highlighted in this study. The study reviewed 12 patients with RA,who were surgically treated for lumbar canal stenosis. Two out of five patients with pulmonary fibrosis died of worsened pulmonary condition, even though there were no perioperative pulmonary complications. Two patients with pedicle screw fixation showed no instrumentation failure, but two patients with spinous process fixation needed re-operation or vertebral fracture. Surgical treatment for lumbar canal stenosis in RA patients needs to be individually adjusted. Preoperative assessments and treatments of pulmonary fibrosis and osteopenia are essential. Surgery for lumbar canal stenosis with RA should be deferred for patients with advanced pulmonary fibrosis because of its potential life-threatening risk. Fusion surgery is indicated only in patients with kyphosis or severe symptoms caused by intervertebral instability. Pedicle screw fixation with hydroxyapatite granules or sublaminar tape is recommended. Closer follow-up after surgery is necessary because of possible delayed wound infection, instrumentation failure, pathological fracture, and respiratory deterioration.
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