Predictors of long-term outcome in an elderly group after laminectomy for lumbar stenosis

The Impact of Preoperative Sagittal Imbalance on Long-term Postoperative Outcomes Following Minimally Invasive Laminectomy

Background: Postoperative sagittal alignment has been shown to be associated with patient-reported outcome measures (PROMs) following open lumbar decompression procedures, although it is unknown whether preoperative sagittal imbalance affects clinical outcomes of minimally invasive surgical (MIS) decompression only surgery. Purpose: We sought to evaluate the impact of preoperative pelvic incidence-lumbar lordosis (PI-LL) imbalance on PROMs after MIS laminectomy for the treatment of neurogenic claudication symptoms. Methods: We conducted a retrospective cohort study of adult patients undergoing MIS laminectomy for degenerative lumbar spinal stenosis between April 2017 and April 2021 at a single institution. Of the 52 patients included (mean follow-up, 17 months) radiographs were taken prior to surgery and assessed for sagittal alignment parameters. Patients were grouped based on the preoperative PI-LL (balanced vs unbalanced). Changes in PROMs were compared between unbalanced PI-LL and balanced PI-LL groups. Minimal clinically important difference (MCID) for Oswestry Disability Index (ODI) was also assessed. Results: Of the 52 patients, 17 (32.7%) had unbalanced age-adjusted preoperative PI-LL. There was no significant difference found in PROMs between unbalanced and balanced PI-LL groups preoperatively or at final follow-up. Compared with those with unbalanced PI-LL, patients with balanced PI-LL were shown to have no added benefit in achieving MCID for ODI at long-term follow-up and no added benefit in the time to achieving MCID. Conclusion: These retrospective findings suggest that patients with unbalanced preoperative PI-LL may experience significant benefit in long-term clinical outcomes following MIS laminectomy, similarly to those with balanced PI-LL at baseline. The findings also suggest that the presence of sagittal imbalance preoperatively may not appreciably influence the long-term clinical outcomes following MIS laminectomy. Prospective study involving a larger population is warranted.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression.

SUMMARY OF BACKGROUND DATA

Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression.

METHODS

Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05.

RESULTS

A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days.

CONCLUSIONS

Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery

INTRODUCTION AND OBJECTIVES

Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery.

MATERIALS AND METHODS

We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide).

RESULTS

Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465).

CONCLUSION

Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.

Association of Mortality and Charlson Comorbidity Index in Surgical Spinal Trauma Patients at a Level I Academic Center

OBJECTIVES

The Charlson Comorbidity Index score (CCI) records the presence of comorbidities with various weights for a total score to estimate mortality within 1 year of hospital admission. Our study sought to assess the association of CCI with mortality rates of patients undergoing surgical intervention.

STUDY DESIGN

Retrospective study.

METHODS

Retrospective study of patients with surgical spinal trauma at a large academic level I trauma tertiary center from 2015 to 2018. Information collected included age, sex, American Society of Anesthesiologists physical status, body mass index, Charlson comorbidities, injury severity score, the presence of spinal cord injury, and mortality. Mortality was measured at 30 days, 90 days, and 1 year. Descriptive and bivariate analyses were completed. The results were significant at P < 0.05.

RESULTS

The highest proportion of 1-year mortality was in the patients with cervical (11.3%) and thoracolumbar injuries (7.4%) (P = 0.002). Patients with low CCI had low 1-year mortality (1.7%). Patients with high CCI had high 1-year mortality (13.8%) (P < 0.001). A significant association existed between CCI and mortality at 30 days, 90 days, and 1 year (P < 0.001). Mortality was higher in patients with spinal cord injury (14/108; 13%) than in those without (11/232; 5%) (P = 0.021). No association existed between ISS and mortality (P = 0.26).

DISCUSSION

The CCI was associated with a higher proportion of deaths at 30 days, 90 days, and 1 year. This association may help predict this unfortunate complication and guide the surgical team in formulating treatment plans and counseling patients and families regarding mortality associated with these injuries and the risks of surgical intervention.

Association between depression and anxiety on symptom and function after surgery for lumbar spinal stenosis

Evidence on the role of depression and anxiety in patients undergoing surgical treatment for symptomatic degenerative lumbar spinal stenosis (DLSS) is conflicting. We aimed to assess the association between depression and anxiety with symptoms and function in patients undergoing surgery for DLSS. Included were patients with symptomatic DLSS participating in a prospective multicentre cohort study who underwent surgery and completed the 24-month follow-up. We used the hospital anxiety and depression scale (HADS) to assess depression/anxiety. We used mixed-effects models to quantify the impact on the primary outcome change in the spinal stenosis measure (SSM) symptoms/function subscale from baseline to 12- and 24-months. Logistic regression analysis was used to quantify the odds of the SSM to reach a minimal clinically important difference (MCID) at 24 months follow-up. The robustness of the results in the presence of unmeasured confounding was quantified using a benchmarking method based on a multiple linear model. Out of 401 patients 72 (17.95%) were depressed and 80 anxious (19.05%). Depression was associated with more symptoms (β = 0.36, 95% confidence interval (CI) 0.20 to 0.51, p < 0.001) and worse function (β = 0.37, 95% CI 0.24 to 0.50, p < 0.001) at 12- and 24-months. Only the association between baseline depression and SSM symptoms/function was robust at 12 and 24 months. There was no evidence for baseline depression/anxiety decreasing odds for a MCID in SSM symptoms and function over time. In patients undergoing surgery for symptomatic DLSS, preoperative depression but not anxiety was associated with more severe symptoms and disability at 12 and 24 months.

Reducing Postoperative Opioid-prescribing Following Posterior Lumbar Fusion Does Not Significantly Change Patient Satisfaction

STUDY DESIGN

Retrospective comparative; LOE-3.

OBJECTIVE

The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following one- or two-level lumbar fusion has on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results.

SUMMARY OF BACKGROUND DATA

Previous research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction.

METHODS

A retrospective review of prospectively collected data was conducted on patients who underwent one- or two-level lumbar fusions L3-S1 between October 2014 and October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions more than two levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram morphine equivalents (MME).

RESULTS

A total of 330 patients met inclusion criteria: 259 pre-protocol, 71 post-protocol. There were 256 one-level fusions and 74 two-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (P > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7% (95) pre-protocol to 59.2% (42) post-protocol; P < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL (P = 0.003). Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3% (P < 0.001). Average opioids prescribed on discharge in the pre-protocol period was 534 ± 425 MME, compared to after initiation of the protocol, that is 320 ± 174 MME (P < 0.001). There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol versus 4.51 ± 0.82 post-protocol (P = 0.986).

CONCLUSION

A reduction in opioids prescribed at discharge after one- or two-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

Impact of leg numbness on patient satisfaction following decompression surgery for lumbar spinal stenosis

Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.

The influence of comorbidities on the treatment outcome in symptomatic lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) affects mainly elderly patients. To this day, it is unclear whether comorbidities influence treatment success. The aim of this systematic review and meta-analysis was to assess the impact of comorbidities on the treatment effectiveness in symptomatic LSS.

METHODS

We conducted a systematic review and meta-analysis and reviewed prospective or retrospective studies from Medline, Embase, Cochrane Library and CINAHL from inception to May 2020, including adult patients with LSS undergoing surgical or conservative treatment. Main outcomes were satisfaction, functional and symptoms improvement, and adverse events (AE). Proportions of outcomes within two subgroups of a comorbidity were compared with risk ratio (RR) as summary measure. Availability of ≥3 studies for the same subgroup and outcome was required for meta-analysis.

RESULTS

Of 72 publications, 51 studies, mostly assessing surgery, there was no evidence reported that patients with comorbidities were less satisfied compared to patients without comorbidities (RR 1.06, 95% confidence interval (CI) 0.77 to 1.45, I 2 94%), but they had an increased risk for AE (RR 1.46, 95% CI 1.06 to 2.01, I 2 72%). A limited number of studies found no influence of comorbidities on functional and symptoms improvement. Older age did not affect satisfaction, symptoms and functional improvement, and AE (age >80 years RR 1.22, 95% CI 0.98 to 1.52, I 2 60%). Diabetes was associated with more AE (RR 1.72, 95% CI 1.19 to 2.47, I 2 58%).

CONCLUSION

In patients with LSS and comorbidities (in particular diabetes), a higher risk for AE should be considered in the treatment decision. Older age alone was not associated with an increased risk for AE, less functional and symptoms improvement, and less treatment satisfaction.

Classification and prognostic factors of residual symptoms after minimally invasive lumbar decompression surgery using a cluster analysis: a 5-year follow-up cohort study

PURPOSE

Residual symptoms indicating incomplete remission of lower leg numbness or low back pain may occur after spine surgery. The purpose was to elucidate the pattern of residual symptoms 5 years after minimally invasive lumbar decompression surgery using a cluster analysis.

METHODS

The study comprised 193 patients with lumbar spinal stenosis (LSS) (108 men, 85 women) ranging in age from 40 to 86 years (mean, 67.9 years). Each patient underwent 5-year follow-up. The Japanese Orthopedic Association score and visual analog scale scores for low back pain, leg pain, and leg numbness at 5 years were entered into the cluster analysis to characterize postoperative residual symptoms. Other clinical data were analyzed to detect the factors significantly related to each cluster.

RESULTS

The analysis yielded four clusters representing different patterns of residual symptoms. Patients in cluster 1 (57.0%) were substantially improved and had few residual symptoms of LSS. Patients in cluster 2 (11.4%) were poorly improved and had major residual symptoms. Patients in cluster 3 (17.6%) were greatly improved but had mild residual low back pain. Patients in cluster 4 (14.0%) were improved but had severe residual leg numbness. Prognostic factors of cluster 2 were a short maximum walking distance, motor weakness, resting lower leg numbness, cofounding scoliosis, and high sagittal vertical axis.

CONCLUSIONS

This is the first study to identify specific patterns of residual symptoms of LSS after decompression surgery. Our results will contribute to acquisition of preoperative informed consent and identification of patients with the best chance of postoperative improvement.

Factors Influencing Patient Satisfaction After Decompression Surgery Without Fusion for Lumbar Spinal Stenosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Decompression without fusion is a standard surgical treatment for lumbar spinal stenosis (LSS) with reasonable surgical outcomes. Nevertheless, some studies have reported low patient satisfaction (PS) following decompression surgery. The cause of the discrepancy between reasonable clinical outcomes and PS is unknown; moreover, the factors associated with PS are expected to be complex, and little is known about them. This study aimed to identify satisfaction rate and to clarify the factors related to PS following decompression surgery in LSS patients.

METHODS

We retrospectively reviewed 126 patients who underwent lumbar decompression with a minimum follow-up of 1 year. Patients were divided into 2 groups based on the PS question. The Japanese Orthopaedic Association (JOA) scores, and the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness were compared between the 2 groups preoperatively and at the latest visit. To identify the prognostic factors for dissatisfaction, multiple logistic regression analysis was performed.

RESULTS

Overall satisfaction rate was 75%. The JOA recovery rate, NRS improvement, and Short Form-8 (SF-8) were significantly higher in the satisfied group. Postoperative NRS scores of LBP, leg pain, and leg numbness were significantly lower in the satisfied group. Multivariate logistic regression analysis showed that smoking and scoliosis were significant risk factors for dissatisfaction.

CONCLUSIONS

Overall satisfaction rate was 75% in patients with LSS undergoing decompression surgery. This study found that smoking status and scoliosis were associated with patient dissatisfaction following decompression in LSS patients.

Gender differences in the surgical management of lumbar degenerative disease: a scoping review

OBJECTIVE

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis).

METHODS

A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected.

RESULTS

Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females.

CONCLUSIONS

Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

Risk factors for persistent numbness following decompression surgery for lumbar spinal stenosis

OBJECTIVE

Decompression surgery is a mainstay of surgical treatment for lumbar spinal stenosis (LSS). However, up to 30% of patients have low satisfaction due to residual symptoms. In the clinical setting, improvements in leg pain are more significant than those in leg numbness. Residual numbness could be related to the relatively low satisfaction rate. However, few studies have focused on numbness; thus, elucidating the risk factors and rate of residual numbness would benefit surgeons and patients. This study aimed to clarify the risk factors for and rate of residual numbness after decompression surgery.

PATIENTS AND METHODS

We retrospectively reviewed prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between January 2014 and March 2016. Patients were included if preoperative and final follow-up questionnaires and radiographs were available. A minimum one-year follow-up was required. We evaluated the Numeric Rating Scale (NRS) scores of low back pain, leg pain, and leg numbness preoperatively and at the final follow-up visit. Residual numbness was defined as a postoperative NRS ≥ 1, whereas persistent numbness was defined as a postoperative NRS ≥ 5. We compared the clinical data of patients with or without residual numbness to those of patients with or without persistent numbness. Multivariate logistic regression analysis was performed to identify risk factors for residual and persistent numbness.

RESULTS

A total of 116 patients (73 men, 43 women) were included. Of them, 60% had residual numbness with a mean follow-up period of 25 months. Only durotomy differed significantly between patients with and those without residual numbness. However, the significance did not persist after logistic regression analysis. A total of 16% had persistent numbness. Diabetes mellitus, intraoperative durotomy, and preoperative NRS of numbness were identified as risk factors. There were no differences in smoking status, presence of spondylolisthesis or scoliosis, or severity of stenosis.

CONCLUSIONS

We found three risk factors for persistent numbness following decompression surgery for LSS; diabetes mellitus and durotomy were modifiable, whereas preoperative numbness was not. Our findings would help surgeons minimize the incidence of persistent numbness by adequately controlling diabetes and avoiding durotomy during surgery. Providing information about the potential for residual numbness during the informed consent process is important to ensuring realistic patient expectations.

Patient Satisfaction in Spine Surgery: A Systematic Review of the Literature

Patient satisfaction reflects the patients' perception of the outcome of care and is being considered for use in future reimbursement schemes. No consensus exists regarding the best instrument to measure patient satisfaction in the field of spine surgery. This systematic review aimed to determine how patient satisfaction for spine surgery has been measured previously and whether a disease-specific, comprehensive instrument to measure patient satisfaction has been established; we also aimed to define the dimensions of care that determine patient satisfaction in spine surgery. A systematic search of three online databases, unpublished sources, and citations was undertaken to identify 156 empirical studies that reported on patient satisfaction in the field of spine surgery. Manuscripts were reviewed in terms of the patient satisfaction instrument used, and the instruments were categorized as per content and method axes. Taxonomy of patient satisfaction with spine surgery identified the major characteristics of providers and medical care that influenced patient satisfaction and acted as a structure to categorically define the dimensions of patient satisfaction in spine surgery. The reviewed studies predominantly used global (108/156) rather than multidimensional (46/156), instruments. Most studies (96.2%) reported satisfaction with outcome rather than with care, and only 18.5% of the studies (29/156) utilized a disease-specific instrument. The following seven dimensions of patient status, outcome, and care experience that affected patient satisfaction were identified: pain, function, patient expectations/preference, specific patient health characteristics, caregiver interpersonal manner, efficacy/clinical outcomes, and postoperative care/therapy. Currently, no disease-specific instrument that includes all dimensions of patient satisfaction in spine surgery has been developed. Such a patient satisfaction instrument should be designed, tested for reliability and validity, and widely implemented.

The influence of hand grip strength on surgical outcomes after surgery for degenerative lumbar spinal stenosis: a preliminary result

BACKGROUND CONTEXT

Although a number of prognostic factors have been demonstrated to be associated with surgical outcome of degenerative lumbar spinal stenosis (DLSS), no study has investigated the relation between hand grip strength (HGS) and treatment outcome of DLSS.

PURPOSE

The purpose of the present study was to examine the influence of HGS on surgical outcomes after surgery for patients with DLSS.

STUDY DESIGN

This is an observational study.

PATIENT SAMPLE

Patients who underwent spine surgery for DLSS were included in the study.

OUTCOME MEASURES

Oswestry Disability Index (ODI), EuroQOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain were assessed.

MATERIALS AND METHODS

A total of 172 consecutive patients who underwent spine surgery for DLSS were included in the present study. Patients were assigned to either high HGS group (≥26 kg for men and ≥18 kg for women, n=124) or low HGS group (<26 kg for men and <18 kg for women, n=48) based on their preoperative HGS performance. Oswestry Disability Index, EQ-5D, and VAS scores for back and leg pain were assessed and compared between two groups preoperatively, 3 and 6 months after surgery. The primary outcome measure was baseline-adjusted ODI scores 6 months after surgery. The secondary outcome measures, including the overall ODI score, EQ-5D score, VAS score for back and leg pain, were assessed at each time point during the 6-month follow-up period.

RESULTS

As primary outcome, baseline-adjusted ODI scores were significantly lower in the high HGS group than in the low HGS group 6 months after surgery. In the secondary outcome measurements, the ODI, EQ-5D, and VAS scores for back and leg pain improved significantly with time after surgery in both groups. The effects of HGS group on the overall changes in the ODI and EQ-5D scores during the 6-month period were significantly different between the two groups; however, they were not significantly different on VAS score for back and leg pain. The pattern of change in the ODI during the follow-up period was significantly different between the two groups.

CONCLUSIONS

Patients with preoperative high HGS display better surgical outcome in terms of disability and health status 6 months after spine surgery. Preoperative HGS can act as a predictor of surgical outcome in patients with DLSS.

Minimally Invasive Decompression and Physiotherapy for Lumbar Spinal Stenosis in Geriatric Patients

Background Lumbar spinal stenosis (LSS) is the most common indication for spine surgery among the geriatric population. Although decompressive surgery is effective, older patients do not benefit as much as younger patients, and they are frequently excluded from studies assessing postoperative physiotherapy. We sought to evaluate the long-term outcomes after surgery when a novel postoperative physiotherapy regimen was included. Methods We performed a retrospective review of patients with LSS greater than 70 years old who underwent lumbar decompressive surgery by the senior author over the past five years. We evaluated patients who participated in a novel postoperative physiotherapy regimen involving four phases of rehabilitation aimed at progressively independent ambulation. The visual analog scale (VAS), lower extremity motor strength, and functional independence measure (FIM) were collected preoperatively and after physiotherapy to measure outcomes. Results Ten consecutive patients with an average age of 83 years (range: 71 - 96) met the inclusion criteria. Nine patients underwent minimally invasive laminotomies at L4-L5 and one underwent a laminotomy at L3-L4. The average follow-up time was 41.9 months. The preoperative mean VAS was 7.35, and at the end of the study, it was 1.7 (p = 0.005). Three of the four patients with preoperative motor deficits improved. The median transfer and locomotion subscores of the FIM were six preoperatively and increased to seven postoperatively. Neither of these improvements was significant. Conclusions Patients older than 70 years undergoing decompressive surgery and a novel postoperative physiotherapy regimen experienced significant reductions in pain. Independence also increased; however, this did not reach statistical significance.

Identifying predictors for postoperative clinical outcome in lumbar spinal stenosis patients using smart-shoe technology

BACKGROUND

Approximately 33% of the patients with lumbar spinal stenosis (LSS) who undergo surgery are not satisfied with their postoperative clinical outcomes. Therefore, identifying predictors for postoperative outcome and groups of patients who will benefit from the surgical intervention is of significant clinical benefit. However, many of the studied predictors to date suffer from subjective recall bias, lack fine digital measures, and yield poor correlation to outcomes.

METHODS

This study utilized smart-shoes to capture gait parameters extracted preoperatively during a 10 m self-paced walking test, which was hypothesized to provide objective, digital measurements regarding the level of gait impairment caused by LSS symptoms, with the goal of predicting postoperative outcomes in a cohort of LSS patients who received lumbar decompression and/or fusion surgery. The Oswestry Disability Index (ODI) and predominant pain level measured via the Visual Analogue Scale (VAS) were used as the postoperative clinical outcome variables.

RESULTS

The gait parameters extracted from the smart-shoes made statistically significant predictions of the postoperative improvement in ODI (RMSE =0.13, r=0.93, and p<3.92×10-7) and predominant pain level (RMSE =0.19, r=0.83, and p<1.28×10-4). Additionally, the gait parameters produced greater prediction accuracy compared to the clinical variables that had been previously investigated.

CONCLUSIONS

The reported results herein support the hypothesis that the measurement of gait characteristics by our smart-shoe system can provide accurate predictions of the surgical outcomes, assisting clinicians in identifying which LSS patient population can benefit from the surgical intervention and optimize treatment strategies.

Prognostic Factors for Satisfaction After Decompression Surgery for Lumbar Spinal Stenosis

BACKGROUND

Surgical treatment for lumbar spinal stenosis is associated with both short- and long-term benefits with improvements in patient function and pain. Even though most patients are satisfied postoperatively, some studies report that up to one-third of patients are dissatisfied.

OBJECTIVE

To present clinical outcome data and identify prognostic factors related to patient satisfaction 1 yr after posterior decompression surgery for lumbar spinal stenosis.

METHODS

This multicenter register study included 2562 patients. Patients were treated with various types of posterior decompression. Patients with previous spine surgery or concomitant fusion were excluded. Patient satisfaction was analyzed for associations with age, sex, body mass index, smoking status, duration of pain, number of decompressed vertebral levels, comorbidities, and patient-reported outcome measures, which were used to quantify the effect of the surgical intervention.

RESULTS

At 1-yr follow-up, 62.4% of patients were satisfied but 15.1% reported dissatisfaction. The satisfied patients showed significantly greater improvement in all outcome measures compared to the dissatisfied patients. The outcome scores for the dissatisfied patients were relatively unchanged or worse compared to baseline. Association was seen between dissatisfaction, duration of leg pain, smoking status, and patient comorbidities. Patients with good walking capacity at baseline were less prone to be dissatisfied compared to patients with poor walking capacity.

CONCLUSION

This study found smoking, long duration of leg pain, and cancerous and neurological disease to be associated with patient dissatisfaction, whereas good walking capacity at baseline was positively associated with satisfaction after 1 yr.

Psychosocial factors and surgical outcomes: are elderly depressed patients less satisfied with surgery?

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVE

In this study, we set out to assess the effect of preoperative depression on patient satisfaction after revision lumbar surgery.

SUMMARY OF BACKGROUND DATA

Patient satisfaction ratings are increasingly being used in health care as a proxy for quality of care. In the elderly, affective disorders such as depression have been shown to influence patient-reported outcomes and self-interpretation of health status.

METHODS

A total of 69 patients aged 65 years or older undergoing revision neural decompression and instrumented fusion for same-level recurrent stenosis-associated back and leg pain were included in this study. Preoperative Zung self-rating depression score, comorbidities, and postoperative satisfaction with surgical care and outcome were assessed for all patients. Baseline and 2-year visual analogue scale (VAS)-leg pain, VAS-back pain, Oswestry Disability Index, Short Form-12 physical component score and Short Form-12 mental component score, as well as health-state utility (EuroQol 5D) were assessed. Factors associated with patient satisfaction after surgical procedures were assessed via multivariate logistic regression analysis.

RESULTS

Compared with baseline, there was a statistically significant improvement in VAS-back pain 2.76±2.73 (pseudarthrosis [1.94±2.81], adjacent segment disease [4.35±3.16]), same-level recurrent stenosis [2±2.23]), VAS-leg pain 2.66±4.12, (adjacent segment disease [2.24±4.46] and same-level recurrent stenosis [3±3.78]). Two-year Oswestry Disability Index improved after surgery for pseudarthrosis (4.05±7.65), adjacent segment disease (6±13.63) and same-level recurrent stenosis (4.54±5.97). In a multivariate logistical regression model, increasing preoperative Zung self-rating depression scale scores were independently associated with patient dissatisfaction 2 years after revision lumbar surgery, (P<0.001).

CONCLUSION

This study demonstrates that independent of surgical effectiveness, baseline depression influence patient satisfaction with health care, 2 years after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality of care should account for patients' baseline depression as a potential confounder especially in this age group.

LEVEL OF EVIDENCE

3.

Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article

OBJECT

The development of minimally invasive surgical techniques is driven by the quest for better patient outcomes. There is some evidence for the use of minimally invasive surgery for degenerative lumbar spine stenosis (LSS), but there are currently no studies comparing outcomes with matched controls. The object of this study was to compare outcomes following minimally invasive unilateral laminectomy for bilateral decompression (ULBD) to a standard "open" laminectomy for LSS.

METHODS

The authors conducted a prospective, 1:1 randomized trial comparing ULBD to open laminectomy for degenerative LSS. The study enrolled 79 patients between 2007 and 2009, and adequate data for analysis were available in 54 patients (27 in each arm of the study). Patient demographic characteristics and clinical characteristics were recorded and clinical outcomes were obtained using pre- and postoperative Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for leg pain, patient satisfaction index scores, and postoperative 12-Item Short Form Health Survey (SF-12) scores.

RESULTS

Significant improvements were observed in ODI and VAS scores for both open and ULBD interventions (p < 0.001 for both groups using either score). In addition, the ULBD-treated patients had a significantly better mean improvement in the VAS scores (p = 0.013) but not the ODI scores (p = 0.055) compared with patients in the open-surgery group. ULBD-treated patients had a significantly shorter length of postoperative hospital stay (55.1 vs. 100.8 hours, p = 0.0041) and time to mobilization (15.6 vs. 33.3 hours, p < 0.001) and were more likely to not use opioids for postoperative pain (51.9% vs. 15.4%, p = 0.046).

CONCLUSIONS

Based on short-term follow-up, microscopic ULBD is as effective as open decompression in improving function (ODI score), with the additional benefits of a significantly greater decrease in pain (VAS score), postoperative recovery time, time to mobilization, and opioid use.

Depression as a prognostic factor of lumbar spinal stenosis: a systematic review

BACKGROUND CONTEXT

The clinical syndrome of lumbar spinal stenosis (LSS) is a commonly diagnosed lumbar condition associated with pain and disability. Psychological factors, including depression, also affect these and other health-related outcomes. Yet, the prognostic value of depression specifically in the context of LSS is unclear.

PURPOSE

The aim of this systematic review was to examine the literature on depression as a prognostic factor of outcomes in patients with LSS.

STUDY DESIGN

Best-evidence synthesis.

PATIENT SAMPLE

Patients receiving the diagnosis of LSS and surgery.

METHODS

A best-evidence synthesis was conducted, including articles published between 1980 and May 2012. Each article meeting inclusion criteria, including a longitudinal design, was critically appraised on its methodological quality by two authors independently, who then met to reach consensus. Only studies deemed scientifically admissible were included in the review.

RESULTS

Among the 20 articles that met the inclusion criteria, 13 were judged scientifically admissible. The evidence supports an association between preoperative depression and postoperative LSS-related symptom severity (a combination of pain, numbness, weakness and balance issues) and disability. The effect size for these associations was variable, ranging from no effect to a moderate effect. For example, an increase of 5 points on a 63-point depression scale doubled the odds of being below the median in LSS-related symptom severity at follow-up. Findings on the association between preoperative depression and postoperative pain alone and walking capacity were more variable.

CONCLUSIONS

Findings support that preoperative depression is likely a prognostic factor for postoperative LSS-related symptom severity and disability at various follow-up points. The prognostic value of depression on the outcomes of pain and walking capacity is less clear. Nonetheless, depression should be considered in the clinical care of this population.

Health-related quality of life and expectations of patients before surgical treatment of lumbar stenosis

OBJECTIVE: To evaluate the expectations of patients awaiting surgical treatment of lumbar canal stenosis and the association of Health-Related Quality of Life (HRQoL) with symptoms of anxiety and depression. METHODS: The sample included 49 patients from a university hospital. HRQoL was assessed by the Oswestry Disability Index (ODI) and 36-item Medical Outcomes Survey Short Form (SF-36) and symptoms of anxiety and depression by the Hospital Anxiety and Depression Scale (HADS). Expectations were investigated by means of questions used in international studies. Data were analyzed descriptively and by Student's t test. RESULTS: The mean time of disease progression was 34.5 months, the mean age was 58.8 years and 55.1% of the patients were women. Most patients had the expectation of improving with surgical treatment and 46.9% expected to be "much better" with regard to leg pain, walking ability, independence in activities and mental well being. The scores of anxiety and depression were respectively, 34.7% and 12.2%. We observed statistically significant differences between the groups with and without anxiety in the domains: General Health, Mental Health, and Vitality. Between the groups with and without depression there were statistically significant differences in the General Health and Mental Health domains. CONCLUSION: Patients showed great expectation to surgical treatment and the symptoms of anxiety and depression were related to some domains of HRQoL. Thus, the study contributes to broaden our knowledge and we can therefore guide the patients as to their expectations with respect to the real possibilities arising from surgery.

Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To identify predictors of 30-day complications after the surgical treatment of spinal metastasis.

SUMMARY OF BACKGROUND DATA

Surgical treatment of spinal metastasis is considered palliative with the aim of reducing or delaying neurologic deficit. Postoperative complication rates as high as 39% have been reported in the literature. Complications may impact patient quality of life and increase costs; therefore, an understanding of which preoperative variables best predict 30-day complications will help risk-stratify patients and guide therapeutic decision making and informed consent.

METHODS

We retrospectively reviewed 200 cases of spinal metastasis surgically treated at Stanford Hospital between 1999 and 2009. Multiple logistic regression was performed to determine which preoperative variables were independent predictors of 30-day complications.

RESULTS

Sixty-eight patients (34%) experienced one or more complications within 30 days of surgery. The most common complications were respiratory failure, venous thromboembolism, and pneumonia. On multivariate analysis, Charlson Comorbidity Index score was the most significant predictor of 30-day complications. Patients with a Charlson score of two or greater had over five times the odds of a 30-day complication as patients with a score of zero or one.

CONCLUSION

After adjusting for demographic, oncologic, neurologic, operative, and health factors, Charlson score was the most robust predictor of 30-day complications. A Charlson score of two or greater should be considered a surgical risk factor for 30-day complications, and should be used to risk-stratify surgical candidates. If complications are anticipated, medical staff can prepare in advance, for instance, scheduling aggressive ICU care to monitor for and treat complications. Finally, Charlson score should be controlled for in future spinal metastasis outcomes studies and compared to other comorbidity assessment tools.