Impact of instrumentation in lumbar spinal fusion in elderly patients: 71 patients followed for 2-7 years

Enhanced recovery after surgery (ERAS) improves outcomes in elderly patients undergoing short-level lumbar fusion surgery: a retrospective study of 333 cases

BACKGROUND

Degenerative lumbar disease significantly impairs the quality of life in elderly individuals, with short-segment lumbar degenerative disease being particularly prevalent. When conservative treatment proves ineffective, surgical intervention becomes the optimal choice for managing lumbar disease. The implementation of Enhanced Recovery After Surgery (ERAS) in spinal surgery has been progressively refined, leading to greater patient benefits. However, age and the associated decline in physiological function remain critical factors influencing surgical decision-making. Currently, there is a paucity of research focused on elderly patients undergoing lumbar fusion surgery to substantiate that advanced age does not diminish the benefits derived from ERAS in this demographic.

METHODS

This is a retrospective cohort study of prospectively collected data. Patients who underwent short-segment (1 or 2 segments) transforaminal lumbar interbody fusion (TLIF) under the care of the same surgical team at our institution were recruited, and divided into no-ERAS-elder, ERAS-elder, and ERAS-younger groups. Subsequently, time to physiological function recovery and other outcomes were compared.

RESULTS

The outcomes of the ERAS-elder group (n = 113) and the no-ERAS-elder group (n = 120) were compared. The overall physiological function recovery was significantly faster (6.71 ± 2.6 days vs. 8.6 ± 2.67 days, p = 0.01) in the ERAS-elder group. Next, the outcomes of the ERAS-elder group (n = 113) were compared with those of the ERAS-younger group (n = 100), and no significant difference in total physiological function recovery was found between the two groups (6.71 ± 2.6 days vs. 6.14 ± 1.63 days, p = 0.252).

CONCLUSIONS

This study shows that the implementation of the ERAS program can effectively shorten the recovery time of physiological function in elderly patients after short-segment lumbar surgery, reduce the incidence of some complications, alleviate pain, and significantly shorten the length of hospital stay. ERAS enables elderly patients to achieve outcomes comparable to those of younger patients.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery.

METHODS

A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65 years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho.

RESULTS

272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944.

CONCLUSIONS

The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.

Instrumented lumbar fusion in patients over 75 years of age: is it worthwhile?-a comparative study of the improvement in quality of life between elderly and young patients

Background

Surgical treatment of degenerative lumbar disease in the elderly is controversial. Elderly patients have an increased risk for medical and surgical complications commensurate with their comorbidities, and concerns over complications have led to frequent cases of insufficient decompression to avoid the need for instrumentation. The purpose of this study was to evaluate clinical outcome between older and younger patients undergoing lumbar instrumented arthrodesis.

Methods

This is a retrospective, comparative study of prospectively collected outcomes. One hundred and fifty-four patients underwent 1- or 2-level posterolateral lumbar fusion. Patients were divided into two groups. Group 1: 87 patients ≤65 years of age who underwent decompression and posterolateral instrumented fusion; Group 2: 67 patients ≥75 years of age who underwent the same procedures with polymethylmethacrylate (PMMA) pedicle-screw augmentation. Mean follow-up 27.47 months (range, 76-24 months).

Results

Mean age was 49.1 years old (range, 24-65) for the younger group and 77.8 (range, 75-86) in the elderly group. Patients ≥75 years of age showed higher preoperative comorbidity (American Society of Anesthesiology, ASA: 1.7 vs. 2.4), and ≥2 systemic diseases with greater frequency (12.5% vs. 44.7%). No significant differences were found between the two groups in terms of postoperative complications, fusion, or revision rate. During follow-up, adjacent disc disease and adjacent fracture occurred significantly more in Group 2 (P<0.05). At the end of follow-up, there were no significant differences between the two groups in any of the clinical and health-related quality of life scores or satisfaction with treatment received.

Conclusions

Osteoporosis represents a major consideration before performing spine surgery. Despite an obvious increased risk of complications in elderly patients, PMMA-augmented fenestrated pedicle screw instrumentation in spine fusion represents a safe and effective surgical treatment option to elderly patients with poor bone quality. Age itself should not be considered a contraindication in otherwise appropriately selected patients.

Instrumented Versus Uninstrumented Posterolateral Fusion for Lumbar Spondylolisthesis: A Randomized Controlled Trial

BACKGROUND

In Scandinavia, spinal fusion is frequently performed without instrumentation, as use of instrumentation in the elderly can be complicated by poor bone quality and the risk of screw pull-out. However, uninstrumented fusion carries the risk of nonunion. We performed a randomized controlled trial in an attempt to determine if use of instrumentation leads to better outcomes and fusion rates when spinal fusion is performed for degenerative spondylolisthesis in the elderly.

METHODS

This was a randomized, single-center, open-label trial of patients with symptomatic single-level degenerative spondylolisthesis who were assigned 1:1 to decompression and fusion with or without instrumentation after at least 12 weeks of nonoperative treatment had failed. The primary outcome was the change in the Oswestry Disability Index (ODI), and secondary outcomes included fusion rates within 1 year, reoperation rates within 2 years, and changes in the EuroQol-5 Dimension-3 Level (EQ-5D) score.

RESULTS

Fifty-four subjects were randomized to each of the 2 groups, which had similar preoperative demographic and surgical characteristics. We found similar improvements in the ODI (p = 0.791), back pain, leg pain, and quality of life between groups at 1 and 2 years of follow-up. Solid fusion on computed tomography (CT) scans was noted in 94% of the patients in the instrumented group and 31% in the uninstrumented group (p < 0.001). One patient (2%) in the instrumented group and 7 (13%) in the uninstrumented group (p = 0.031) had a reoperation within 2 years after the index surgery.

CONCLUSIONS

We found no difference in patient-reported outcomes when we compared instrumented with uninstrumented fusion in patients with degenerative spondylolisthesis. The uninstrumented group had a significantly higher rate of nonunion and reoperations at 2 years.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Decompressive laminectomy with instrumented posterolateral fusion for degenerative lumbar disease in elderly, is it safe and beneficial?

Background

With improvement of health care in last decades, the age of general population increased. As the elderly with degenerative lumbar disease needs to remain physically active for more years, lumbar decompression surgery with instrumented fusion is further considered and is gaining wide acceptance as it provides good results with relative minimal risk. This study aim to evaluate the safety and efficacy of lumbar decompression with instrumented fusion in elderly

Results

This is a prospective non-randomized clinical study conducted from July 2014 to July 2019. The included patients had chronic low back pain, radiculopathy, and/or neurogenic claudication due to degenerative lumbar disease with failed conservative management. They underwent lumbar decompression with instrumented posterolateral fusion. All patients were at least 55 years old at time of surgery and were clinically assessed as regard perioperative risk and morbidity, besides assessment of pre- and postoperative visual analog score (VAS) and Oswestry Disability Index (ODI). Data was collected and analyzed. Thirty-five patients were included in this study with mean age of 63 years. All patients presented with back pain, 77.1% with radiculopathy, and 60% with neurogenic claudication. Preoperative comorbidity was present in 60% of cases, where hypertension, diabetes, and cardiac troubles were 31.4%, 31.4%, and 14.3% respectively. The average operated level was 3.1. The complication rate was 11.4% with 2 cases with dural tear (5.7%), 2 cases with CSF leakage (5.7%), 1 case with wound seroma (2.8%), and 1 case with wound infection. Postoperative new comorbidity occurred in 5 cases (14.3%). Visual analog score (VAS) and Oswestry disability index (ODI) were recorded preoperatively and 18 months postoperatively; as regards pain, VAS improved significantly from 7.8 ± 0.87 to 1.8 ± 1.04 (P value< 0.00001), and ODI improved significantly from 58.1 ± 11 to 17.5 ± 8.3 (P value< 0.00001).

Conclusion

Lumbar decompression surgery with posterolateral instrumented fusion is a safe and effective surgery in elderly, as it provides significant results and gives them a chance for better quality of life. Preoperative comorbidity could be dealt with, and it should not be considered as a contraindication for surgery in this age group.

Predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery

OBJECTIVE

As compensation transitions from a fee-for-service to pay-for-performance healthcare model, providers must prioritize patient-centered experiences. Here, the authors' primary aim was to identify predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery.

METHODS

The Michigan Spine Surgery Improvement Collaborative (MSSIC) was queried for all lumbar operations at the 1- and 2-year follow-ups. Predictors of patients' postoperative contentment were identified per the North American Spine Surgery (NASS) Patient Satisfaction Index, wherein satisfied patients were assigned a score of 1 ("the treatment met my expectations") or 2 ("I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome") and unsatisfied patients were assigned a score of 3 ("I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome") or 4 ("I am the same or worse than before treatment"). Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios (RRadj).

RESULTS

Among 5390 patients with a 1-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by higher body mass index (RRadj =1.07, p < 0.001), African American race compared to white (RRadj = 1.51, p < 0.001), education level less than high school graduation compared to a high school diploma or equivalent (RRadj = 1.25, p = 0.008), smoking (RRadj = 1.34, p < 0.001), daily preoperative opioid use > 6 months (RRadj = 1.22, p < 0.001), depression (RRadj = 1.31, p < 0.001), symptom duration > 1 year (RRadj = 1.32, p < 0.001), previous spine surgery (RRadj = 1.32, p < 0.001), and higher baseline numeric rating scale (NRS)-back pain score (RRadj = 1.04, p = 0.002). Conversely, an education level higher than high school graduation, independent ambulation (RRadj = 0.90, p = 0.039), higher baseline NRS-leg pain score (RRadj = 0.97, p = 0.013), and fusion surgery (RRadj = 0.88, p = 0.014) decreased dissatisfaction.Among 2776 patients with a 2-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by a non-white race, current smoking (RRadj = 1.26, p = 0.004), depression (RRadj = 1.34, p < 0.001), symptom duration > 1 year (RRadj = 1.47, p < 0.001), previous spine surgery (RRadj = 1.28, p < 0.001), and higher baseline NRS-back pain score (RRadj = 1.06, p = 0.003). Conversely, at least some college education (RRadj = 0.87, p = 0.035) decreased the risk of dissatisfaction.

CONCLUSIONS

Both comorbid conditions and socioeconomic circumstances must be considered in counseling patients on postoperative expectations. After race, symptom duration was the strongest predictor of dissatisfaction; thus, patient-centered measures must be prioritized. These findings should serve as a tool for surgeons to identify at-risk populations that may need more attention regarding effective communication and additional preoperative counseling to address potential barriers unique to their situation.

An updated meta-analysis of clinical outcomes comparing minimally invasive with open transforaminal lumbar interbody fusion in patients with degenerative lumbar diseases

BACKGROUND & AIMS

Open-transforaminal lumbar interbody fusion (O-TLIF) is regarded as the standard (S) approach which is currently available for patients with degenerative lumbar diseases patients. In addition, minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has proposed and gradually obtained popularity compared with O-TLIF procedures due to its beneficial outcomes in minimized tissue injury and quicker recovery. Nonetheless, debates exist concerning the use of MI-TLIF with its conflicting outcomes of clinical effect and safety in several publications. The purpose of the current study is to conduct an updated meta-analysis to provide eligible and systematical assessment available for the evaluation of the efficacy and safety of MI-TLIF in comparison with O-TLIF.

METHODS

Publications on the comparison of O-TLIF and MI-TLIF in treating degenerative lumbar diseases in last 5 years were collected. After rigorous reviewing on the eligibility of publications, the available data was further extracted from qualified trials. All trials were conducted with the analysis of the summary hazard ratios (HRs) of the interest endpoints, including intraoperative and postoperative outcomes.

RESULTS

Admittedly, it is hard to run a clinical RCT to compare the prognosis of patients undergoing O-TLIF and MI-TLIF. A total of 10 trials including non-randomized trials in the current study were collected according to our inclusion criteria. The pooled results of surgery duration indicated that MI-TLIF was highly associated with shorter length of hospital stay, less blood loss, and less complications. However, there were no remarkable differences in the operate time, VAS-BP, VAS-LP, and ODI between the 2 study groups.

CONCLUSION

The quantitative analysis and combined results of our study suggest that MI-TLIF may be a valid and alternative method with safe profile in comparison of O-TLIF, with reduced blood loss, decreased length of stay, and complication rates. While, no remarkable differences were found or observed in the operate time, VAS-BP, VAS-LP, and ODI. Considering the limited available data and sample size, more RCTs with high quality are demanded to confirm the role of MI-TLIF as a standard approach in treating degenerative lumbar diseases.

Bone regeneration in Ds-Red pig calvarial defect using allogenic transplantation of EGFP-pMSCs - A comparison of host cells and seeding cells in the scaffold

Background

Cells, scaffolds, and factors are the triad of regenerative engineering; however, it is difficult to distinguish whether cells in the regenerative construct are from the seeded cells or host cells via the host blood supply. We performed a novel in vivo study to transplant enhanced green fluorescent pig mesenchymal stem cells (EGFP-pMSCs) into calvarial defect of DsRed pigs. The cell distribution and proportion were distinguished by the different fluorescent colors through the whole regenerative period.

Method/Results

Eight adult domestic Ds-Red pigs were treated with five modalities: empty defects without scaffold (group 1); defects filled only with scaffold (group 2); defects filled with osteoinduction medium-loaded scaffold (group 3); defects filled with 5 x 10³ cells/scaffold (group 4); and defects filled with 5 x 10⁴ cells/scaffold (group 5). The in vitro cell distribution, morphology, osteogenic differentiation, and fluorescence images of groups 4 and 5 were analyzed. Two animals were sacrificed at 1, 2, 3, and 4 weeks after transplantation. The in vivo fluorescence imaging and quantification data showed that EGFP-pMSCs were represented in the scaffolds in groups 4 and 5 throughout the whole regenerative period. A higher seeded cell density resulted in more sustained seeded cells in bone regeneration compared to a lower seeded cell density. Host cells were recruited by seeded cells if enough space was available in the scaffold. Host cells in groups 1 to 3 did not change from the 1st week to 4th week, which indicates that the scaffold without seeded cells cannot recruit host cells even when enough space is available for cell ingrowth. The histological and immunohistochemical data showed that more cells were involved in osteogenesis in scaffolds with seeded cells.

Conclusion

Our in vivo results showed that more seeded cells recruit more host cells and that both cell types participate in osteogenesis. These results suggest that scaffolds without seeded cells may not be effective in bone transplantation.

State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease

Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The practice has evolved continually since Albee and Hibbs independently reported the first cases in 1913, and advancements in both technique and patient selection continue through the present day. Clinical and radiological indications for surgery have been tested in trials, and other diagnostic modalities have developed and been studied. Fusion practices have also advanced; instrumentation, surgical approaches, biologics, and more recently, operative planning, have undergone stark changes at a seemingly increasing pace over the last decade. As the general population ages, treatment of degenerative lumbar disease will become a more prevalent-and costlier-issue for surgeons as well as the healthcare system overall. This review will cover the evolution of indications and techniques for fusion in degenerative lumbar disease, with emphasis on the evidence for current practices.

Predictive model for long-term patient satisfaction after surgery for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database

OBJECTIVE

Since the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.

RESULTS

A total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.

CONCLUSIONS

Current findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

Allograft Versus Demineralized Bone Matrix in Instrumented and Noninstrumented Lumbar Fusion: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The aim was to determine the fusion efficacy of allograft and demineralized bone matrix (DBM) in lumbar instrumented and noninstrumented fusion procedures for degenerative lumbar disorders.

METHODS

A literature search was conducted using the PubMed and Cochrane databases. To be considered, publications had to meet 4 criteria: patients were treated for a degenerative lumbar disorder, a minimum group size of 10 patients, use of allograft or DBM, and at least a 2-year follow-up. Data on the study population, follow-up time, surgery type, grafting material, fusion rates, and its definition were collected.

RESULTS

The search yielded 692 citations with 17 studies meeting the criteria including 4 retrospective and 13 prospective studies. Six studies used DBM and 11 employed allograft alone or in the combination with autograft. For the allograft, fusion rates ranged from 58% to 68% for noninstrumented and from 68% to 98% for instrumented procedures. For DBM, fusion rates were 83% for noninstrumented and between 60% and 100% for instrumented lumbar fusion procedures.

CONCLUSIONS

Both allograft and DBM appeared to provide similar fusion rates in instrumented fusions. On the other hand, in noninstrumented procedures DBM was superior. However, a large variation in the type of surgery, outcomes collection, lack of control groups, and follow-up time prevented any significant conclusions. Thus, studies comparing the performance of allograft and DBM to adequate controls in large, well-defined patient populations and with a sufficient follow-up time are needed to establish the efficacy of these materials as adjuncts to fusion.

Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease

OBJECTIVES

Spinal stabilization surgery is an integral part of the treatment of spinal metastatic disease. Bony fusion is the hallmark of spinal stabilization in non-oncology patients. Spinal oncology patients are unlikely to achieve bony fusion because of their overall prognosis and concurrent therapies. Stabilization surgery without fusion may be a reasonable approach for these patients. Literature evaluating the effectiveness of this approach is limited. The object of this study was to investigate the rate of instrumentation failure in patients undergoing posterior spinal instrumented stabilization without fusion for spinal metastatic disease.

METHODS

Data from consecutive cases of spinal surgery at our institution during an 81-month period were reviewed. Demographics, clinical notes, and computed tomography findings were recorded and used to evaluate instrumentation failures. Patients who underwent separation surgery that included laminectomy and posterior spinal instrumentation without fusion for spinal metastatic disease and had follow-up computed tomography scans >3 months postoperatively were selected for the study.

RESULTS

Twenty-seven patients were included in the study. Mean age was 64.85 ± 6.53 years. Nine patients were women. A mean of 1.61 ± 0.96 laminectomy levels was performed. A mean of 8.26 ± 1.48 screws was inserted. The mean postoperative discharge date was 5.07 ± 1.47 days. Mean follow-up duration was 12.17 ± 11.73 months. None of the patients had a change in instrumentation position, pedicle screw pullout, change in spinal alignment, or progressive deformity. No patient required reoperation or instrumentation revision or replacement.

CONCLUSIONS

Our experience suggests that instrumented spinal stabilization without fusion is an acceptable approach for patients with spinal metastatic disease.

Osteoporosis and the Management of Spinal Degenerative Disease (I)

Osteoporosis has become a major medical problem as the aged population of the world rapidly grows. Osteoporosis predisposes patients to fracture, progressive spinal deformities, and stenosis, and is subject to be a major concern before performing spine surgery, especially with bone fusions and instrumentation. Osteoporosis has often been considered a contraindication for spinal surgery, while in some instances patients have undergone limited and inadequate procedures in order to avoid concomitant instrumentation. As the population ages and the expectations of older patients increase, the demand for surgical treatment in older patients with osteoporosis and spinal degenerative diseases becomes progressively more important. Nowadays, advances in surgical and anesthetic technology make it possible to operate successfully on elderly patients who no longer accept disabling physical conditions. This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal conditions, as well as the novel treatments, recommendations, surgical indications, strategies and instrumentation in patients with osteoporosis who need spine operations.

Surgical outcomes after instrumented lumbar surgery in patients of eighty years of age and older

BACKGROUND

In Taiwan, the life expectancy of an 80-year-old man is 88.4 years and the life expectancy of an 80-year-old woman is 89.8 years. Some of these people will develop symptomatic degenerative lumbar diseases that interfere with an active lifestyle. These older surgical candidates usually ask the surgeon whether it would be safe to undergo surgery. However, there is no literature assessing the outcomes of laminectomy, fusion and posterior fixation for degenerative lumbar diseases in patients older than 80 years. The purpose of this study was to report the surgical outcomes of patients 80 years of age and older who underwent spinal decompression and instrumented lumbar arthrodesis for degeneration lumbar diseases.

METHODS

We retrospectively reviewed patients with degenerative lumbar diseases and spinal stenosis who underwent surgery between January 2010 and December 2012. Inclusion criteria were age greater than or equal to 80 years, decompression with instrumented lumbar arthrodesis, and at least 2 years of follow-up. Totally 89 patients were studies. Clinical outcomes were evaluated according to the Oswestry Disability Index (ODI) and visual analogue scale (VAS) of leg and back pain. Plain radiographs (lateral, anteroposterior, and flexion-extension) were used to assess the status of fusion and implant-related complications. Every complication during admission and any implant-related or failed-back syndrome requiring a second surgery was documented. T test and Fisher's exact test were used for statistical analysis.

RESULTS

Five patients were lost to follow-up, and another 12 died during the follow-up period. One patient died due to cerebral stroke just 2 days after surgery, and the other 11 patients passed away 3 months to 4 years postoperatively. In all, 72 patients had an adequate follow-up: 44 were female and 28 were male. The average age at surgery was 82.5 ± 2.6 years (80 to 93); 63 patients underwent their first lumbar surgery, and nine patients received a second surgery. Patients underwent arthrodesis surgeries were from a single-level to a 7-level. Four patients developed complications (5.6 %, 4/72). At the final follow-up, the average ODI score was lower than the preoperative score (30.0 vs. 61.8) (p < 0.001). The average VAS score also showed improvement (leg: p < 0.001; back: p < 0.001). Forty-three patients were classified as "satisfied", and 29 were "dissatisfied". Longer operation time (p = 0.014) and development of complications (p = 0.049) were related to poor clinical results. Radiographic follow-up showed that 53 patients had solid union, ten had a probable union, and nine had pseudarthrosis. More surgical segments led to a greater chance of pseudarthrosis (2.0 ± 0.9 vs 3.0 ± 1.8, p = 0.003).

CONCLUSION

Longer instrumented segments and development of complications contributed to worse clinical and radiographic outcomes. With proper patient selection, posterior decompression with instrumented fusion can be safe and effective for patients 80 years of age and older with degenerative lumbar conditions.

Low reoperation rate following 336 multilevel lumbar laminectomies with noninstrumented fusions

Background:

Few reoperations are required in older patients undergoing multilevel lumbar laminectomy with noninstrumented fusions for spinal stenosis with/without spondylolisthesis/instability, and they rarely require instrumentation.

Methods:

We reviewed 336 patients averaging 66.5 years of age undergoing initial average 4.7 level lumbar laminectomies with average 1.4 level noninstrumented fusions over an average 7.1-year period (range 2.0–16.5 years). Patients uniformly exhibited spinal stenosis, instability (Grade I [195 patients] or Grade II spondylolisthesis [67 patients]), disc herniations (154 patients), and/or synovial cysts (66 patients). Reoperations, including for adjacent segment disease (ASD), addressed new/recurrent pathology.

Results:

Nine (2.7%) of 336 patients required reoperations, including for ASD, an average of 6.3 years (range 2–15 years) following initial 4.7 level laminectomies with 1.4 level noninstrumented fusions. Second operations warranted average 4.8 level (range 3–6) laminectomies and average 1.1 level non instrumented fusions addressing stenosis with instability (Grade I [7 patients] or Grade II [1 patient] spondylolisthesis), new disc herniations (2 patients), and/or a synovial cyst (1 patient).

Conclusions:

Only 9 (2.7%) of 336 patients required reoperations (including for ASD) consisting of multilevel laminectomies with noninstrumented fusions for recurrent/new stenosis even with instability; these older patients were not typically unstable, or were likely already fused, and did not require instrumentation. Alternatively, reoperation rates following instrumented fusions in other series approached 80% at 5 postoperative years. Therefore, we as spinal surgeons should realize that older patients even with instability rarely require instrumentation and that the practice of performing instrumented fusions in everyone, irrespective of age, needs to stop.

A review: Reduced reoperation rate for multilevel lumbar laminectomies with noninstrumented versus instrumented fusions

Background:

The reoperation rate, including for adjacent segment disease (ASD), is lower following multilevel lumbar laminectomy with noninstrumented versus instrumented fusions.

Methods:

This study reviews selected literature focusing on the reoperation rate, including for ASD, following multilevel laminectomies with noninstrumented versus instrumented fusions. Several prior studies document a 1.3–5.6% reoperation rate following multilevel laminectomy with/without noninstrumented fusions.

Results:

The reoperation rates for instrumented fusions, including for ASD, are substantially higher. One study cited a 12.2–18.5% frequency for reoperation following instrumented transforaminal lumbar and posterior lumbar interbody fusions (TLIF and PLIFs) at an average of 164 postoperative months. Another study cited a 9.9% reoperation rate for ASD 1 year following PLIF; this increased to 80% at 5 postoperative years. A further study compared 380 patients variously undergoing laminectomies/noninstrumented posterolateral fusions, laminectomies with instrumented fusions (PLFs), and laminectomies with instrumented PLF plus an interbody fusions; this study documented no significant differences in outcomes for any of these operations at 4 postoperative years. Furthermore, other series showed fusion rates for 1–2 level procedures which were often similar with or without instrumentation, while instrumentation increased reoperation rates and morbidity.

Conclusions:

Many studies document no benefit for adding instrumentation to laminectomies performed for degenerative disease, including spondylolisthesis. Reoperation rates for laminectomy alone/laminectomy with noninstrumented fusions vary from 1.3% to 5.6% whereas reoperation rates for ASD after instrumented PLIF was 80% at 5 postoperative years. This review should prompt spinal surgeons to reexamine when, why, and whether instrumentation is really necessary, particularly for treating degenerative lumbar disease.

Minimally invasive versus open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease: systematic review and meta-analysis

PURPOSE

While open TLIF (O-TLIF) remains the mainstay approach, minimally invasive TLIF (MI-TLIF) may offer potential advantages of reduced trauma to paraspinal muscles, minimized perioperative blood loss, quicker recovery and reduced risk of infection at surgical sites. This meta-analysis was conducted to provide an updated assessment of the relative benefits and risks of MI-TLIF versus O-TLIF.

METHODS

Electronic searches were performed using six databases from their inception to December 2014. Relevant studies comparing MI-TLIF and O-TLIF were included. Data were extracted and analysed according to predefined clinical end points.

RESULTS

There was no significant difference in operation time noted between MI-TLIF and O-TLIF cohorts. The median intraoperative blood loss for MI-TLIF was significantly lower than O-TLIF (median: 177 vs 461 mL; (weighted mean difference) WMD, -256.23; 95% CI -351.35, -161.1; P < 0.00001). Infection rates were significantly lower in the minimally invasive cohort (1.2 vs 4.6%; relative risk (RR), 0.27; 95%, 0.14, 0.53; I2) = 0%; P = 0.0001). VAS back pain scores were significantly lower in the MI-TLIF group compared to O-TLIF (WMD, -0.41; 95% CI -0.76, -0.06; I2 = 96%; P < 0.00001). Postoperative ODI scores were also significantly lower in the minimally invasive cohort (WMD, -2.21; 95% CI -4.26, -0.15; I2 = 93%; P = 0.04).

CONCLUSIONS

In summary, the present systematic review and meta-analysis demonstrated that MI-TLIF appears to be a safe and efficacious approach compared to O-TLIF. MI-TLIF is associated with lower blood loss and infection rates in patients, albeit at the risk of higher radiation exposure for the surgical team. The long-term relative merits require further validation in prospective, randomized studies.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 12: Pedicle screw fixation as an adjunct to posterolateral fusion

The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: Bone growth stimulators as an adjunct for lumbar fusion

The relationship between the formation of a solid arthrodesis and electrical and electromagnetic energy is well established; most of the information on the topic, however, pertains to the healing of long bone fractures. The use of both invasive and noninvasive means to supply this energy and supplement spinal fusions has been investigated. Three forms of electrical stimulation are routinely used: direct current stimulation (DCS), pulsed electromagnetic field stimulation (PEMFS), and capacitive coupled electrical stimulation (CCES). Only DCS requires the placement of electrodes within the fusion substrate and is inserted at the time of surgery. Since publication of the original guidelines, few studies have investigated the use of bone growth stimulators. Based on the current review, no conflict with the previous recommendations was generated. The use of DCS is recommended as an option for patients younger than 60 years of age, since a positive effect on fusion has been observed. The same, however, cannot be stated for patients over 60, because DCS did not appear to have an impact on fusion rates in this population. No study was reviewed that investigated the use of CCES or the routine use of PEMFS. A single low-level study demonstrated a positive impact of PEMFS on patients undergoing revision surgery for pseudarthrosis, but this single study is insufficient to recommend for or against the use of PEMFS in this patient population.

Instrumented fusion surgery in elderly patients (over 75 years old): clinical and radiological results in a series of 53 patients

OBJECTIVE

To evaluate the clinical and radiological outcomes of elderly (>75 years old) patients who underwent spinal instrumented fusion surgery.

METHODS

Patients underwent lumbar pedicle screw fixation and fusion for degenerative spondylolisthesis. Clinical and radiological outcomes were assessed.

RESULTS

53 patients were studied. Pre-operative VAS was 7.8, ODI was 47.6 %. 254 screws were placed (36 single level; 13 double levels and 4 cases three-levels). No mortality occurred. At 18 months follow-up VAS was 4.1, ODI was 21.8 %. A stable fusion was observed in 41 patients (78.8 %); in four cases there was minimal sign of instability and seven patients underwent a second surgery due to screw mobilization.

CONCLUSION

Spinal fixation and fusion in patients older than 75 years old grants good results in terms of quality of life but the rate of morbidity is higher than standard spine surgery. Rate of fusion especially is still a critical point.

Improving the clinical evidence of bone graft substitute technology in lumbar spine surgery

Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry.

Long-term health care utilisation and costs after spinal fusion in elderly patients

PURPOSE

Spinal fusion surgery rates in the elderly are increasing. Cost effectiveness analyses with relatively short-length follow-up have been performed. But the long-term effects in terms of health care use are largely unknown. The aim of the present study was to describe the long-term consequences of spinal fusion surgery in elderly patients on health care use and costs using a health care system perspective.

METHODS

194 patients undergoing spinal fusion between 2001 and 2005 (70 men, 124 women) with a mean age of 70 years (range 59-88) at surgery were included. Average length of follow-up was 6.2 years (range 0.3-9.0 years). Data on resource utilisation and costs were obtained from national registers providing complete coverage of all reimbursed contacts with primary- and secondary health care providers. Data were available from 3 years prior fusion surgery until the end of 2009.

RESULTS

Use of hospital-based health care increased in the year prior to and the first year following surgery. Hereafter it normalised to the level of the background population and was mainly composed of diseases unrelated to the spine. In contrast, the use of primary health care appeared to increase immediately after surgery and continued to increase to a level that significantly exceeded that of the background population. It could be demonstrated that the increase was mainly due to an increasing number of general practitioner consultations.

CONCLUSION

Spinal fusion surgery in older patients does not generate excess hospital-based health care use in the longer term as compared with the background population, but primary care use increases.

Outcomes of Instrumented Posterolateral Fusion for Patients Over 70 Years with Degenerative Lumbar Spinal Disease: A Minimum of 2 Years Follow-up

Objective

To determine the outcome of posterolateral fusion (PLF) for patients over 70 years of age with degenerative lumbar spinal disease.

Methods

The authors reviewed 18 patients (13 women and 5 men) over 70 years of age who underwent PLF with a minimum 2-years follow-up at a single institution. The parameters for analysis were clinical outcome, intraoperative bleeding, operating time, transfusion amount, fusion rate, decreased disc height at the operated level, and the incidence of adjacent disc degeneration.

Results

The mean age and follow-up duration were 74.1 years and 44.7 months, respectively. The mean fusion level was 2.5 levels. 12 patients (66.7%) reported good or excellent outcomes, and 4 patients complained of poor outcomes. The fusion rate was 61.1%. The rate of adjacent segment degeneration was 61.1%. Among all of the patients, 5 had decreased intervertebral disc heights compared to their initial statuses. In correlative comparison analyses of parameters, a significant correlation was observed between a "good" or better clinical outcome and fusion (p=0.034). Also, there were significant relationships between a "fair" or better clinical outcome and fusion (p=0.045) and decreased disc height at the operated level (p=0.017). Other factors did not have a significant relationship with the clinical outcome.

Conclusions

Before performing instrumented PLF in patients over 70 years old, problems related to the low fusion rate and adjacent segment degeneration should be considered and relevant information should be provided to the patients and the family.

Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies

This clinical study prospectively compares the results of open surgery to minimally invasive fusion for degenerative lumbar spine pathologies. Eighty-two patients were studied (41 minimally invasive surgery [MIS] spinal fusion, 41 open surgical equivalent) under a single surgeon (R. J. Mobbs). The two groups were compared using the Oswestry Disability Index, the Short Form-12 version 1, the Visual Analogue Scale score, the Patient Satisfaction Index, length of hospital stay, time to mobilise, postoperative medication and complications. The MIS cohort was found to have significantly less postoperative pain, and to have met the expectations of a significantly greater proportion of patients than conventional open surgery. The patients who underwent the MIS approach also had significantly shorter length of stay, time to mobilisation, lower opioid use and total complication rates. In our study MIS provided similar efficacy to the conventional open technique, and proved to be superior with regard to patient satisfaction, length of hospital stay, time to mobilise and complication rates.

Instrumented intervertebral or posterolateral fusion in elderly patients: clinical results of a single center

BACKGROUND

Data on the clinical outcome after spinal fusion in the elderly patient are rare. To our knowledge there has been no clinical outcome assessment for instrumented spinal fusion in elderly patients comparing posterolateral fusion with intervertebral fusion. Aim of the current study was to evaluate the clinical outcome of elderly patients who underwent a spinal fusion procedure for degenerative spinal stenosis with instability. Main hypothesis was to test whether it is necessary to force an intervertebral fusion for a better clinical outcome in spinal fusion surgery of the elderly or not.

METHODS

Two subgroups - posterolateral fusion versus intervertebral fusion (cage vs. non-cage) were compared with regard to functional outcome, fusion rates and complications after a mean follow up of 3.8 years. Questionnaires were completed by the patients before surgery and at final follow-up. Changes in mean VAS and ODI scores (decrease from the baseline VAS and ODI scores) were compared.

RESULTS

The mean final follow up for all subjects was 3.8 years. Of the 114 patients, 2 patients were deceased at the time of the follow-up, 5 patients didn't want to participate and 107 patients completed the questionnaires. This resulted in an overall follow-up rate of 93%. At final follow-up, the patients demonstrated significant improvement in the VAS and ODI- compared with the preoperative scores in both groups. But overall there were no significant differences between both groups regarding the outcome assessment using the ODI and VAS.

CONCLUSIONS

The results of this study shows that elderly patients aged over 75 benefit from instrumented lumbar fusion. The study suggests that there is no need to force an intervertebral fusion because elderly patients do not seem to benefit from this procedure.

Health-related quality of life after posterolateral lumbar arthrodesis in patients seventy-five years of age and older

STUDY DESIGN

Retrospective cohort analysis of prospectively collected data.

OBJECTIVE

The purpose of this study is to report health-related quality of life (HRQOL) outcomes in patients 75 years of age and older who underwent one- to two-level instrumented posterolateral lumbar arthrodesis.

SUMMARY OF BACKGROUND DATA

HRQOL measures are increasingly used to measure clinical success after spinal surgery. There is limited data available to guide the clinician caring for the growing geriatric population with degenerative lumbar spine conditions.

METHODS

From a database of prospectively collected HRQOL measures in patients undergoing instrumented lumbar arthrodesis, we identified 35 patients 75 years of age and older who underwent one- or two-level instrumented posterolateral lumbar arthrodesis who had complete preoperative and 2-year postoperative data. HRQOL measures included the Oswestry Disability Index (ODI), Short Form-36 Physical Component Score (PCS) and Mental Component Score (MCS), and back and leg pain numerical rating scales. Paired sample t tests were used to compare preoperative and 2-year postoperative scores. The percentage of patients reaching previously established thresholds for Minimum Clinically Important Difference (MCID) and Substantial Clinical Benefit (SCB) were calculated.

RESULTS

There were 11 men and 24 women with a mean age of 78.3 years (range 75-85). Diagnoses included stenosis (20), spondylolisthesis (12), instability (1), disc pathology (1), and scoliosis (1). Twelve patients (34%) had complications, 8 (23%) major and 4 (11%) minor. There was a statistically significant improvement in all of the HRQOL measures from preoperative to 2-years postoperative. Sixty percent (21 of 35) of the patients reached the MCID threshold for ODI, PCS, and leg pain, whereas 83% (29 of 35) reached the MCID for back pain. More than half of the patients reached the SCB threshold for leg pain (19 of 35, 54%), back pain (21 of 35, 60%), ODI (19 of 35, 54%), and PCS (21 of 35, 60%).

CONCLUSIONS

Properly selected patients 75 years of age and older can achieve substantial clinical improvements, based on patient reported HRQOL measures, 2 years after one- and two-level instrumented posterolateral lumbar arthrodesis.

Instrumented posterolateral fusion - clinical and functional outcome in elderly patients

BACKGROUND

Data on the clinical outcome after spinal fusion in the elderly patient are rare. Limitation of most studies were small population, evaluation of the perioperative complication rate and the radiographic assessment. Therefore the aim of the current study was to evaluate the clinical outcome of patients older than 75 years who underwent a spinal fusion procedure (instrumentation and posterolateral fusion) for degenerative spinal stenosis with instability.

METHODS

Elderly patients who underwent instrumented, posterolateral fusion were evaluated with regard to functional outcome, fusion rates and complications after a mean follow-up of 3.8 years. Questionnaires were completed by the patients before surgery and at final follow-up. Changes in mean visual analogue scale (VAS) and Owestry Disability Index (ODI) scores (decrease from the baseline VAS and ODI scores) were evaluated.

RESULTS

The mean final follow-up for all subjects was 3.8 years. Of the 58 patients, 1 patient was deceased at the time of the follow-up, 1 patient did not want to participate and 56 patients completed the questionnaires. This resulted in an overall follow-up rate of 96%.At final follow-up, the patients demonstrated significant improvement in the VAS and ODI scores compared with the preoperative scores.

CONCLUSIONS

The results of this study shows that elderly patients aged over 75 benefit from instrumented, posterolateral fusion. The study suggests that there is no need to force an intervertebral fusion because elderly patients do not seem to benefit from this procedure.