Adjacent-segment disease in 511 cases of posterolateral instrumented lumbar arthrodesis: floating fusion versus distal construct including the sacrum

The Effect of L5 Morphology on Prevention of L5-S1 Degeneration Following Floating Fusion for Degenerative Spine Disorders

STUDY DESIGN

Retrospective Study.

OBJECTIVES

The selection of floating fusion or lumbosacral fusion arises when treating patients with instability or stenosis of the lower lumbar spine concomitantly radiographic degeneration of L5-S1. This study aimed to investigate the preoperative anatomical or morphological factors affecting the survivorship of the L5-S1 after floating fusion.

METHODS

This study included 77 patients who had undergone floating fusion surgery through the TLIF approach. Preoperative radiographic parameters were evaluated using anteroposterior and lateral lumbar spine radiographs. The patients were divided into two groups according to the Modified Pfirrmann Grading and total endplate score. Multivariable regression analysis was performed to explore the relationships between the anatomical or morphological characteristics of L5 and the degeneration of L5-S1.

RESULTS

The disc degeneration group exhibited a smaller height ratio of the iliac crest (Hi) and a less L5 deep position. Furthermore, the right/left height of L4 (Hr/Hl) and the right/left width of transverse process of L5 (CRt/CLt) were significantly higher in the disc and endplate degeneration groups. Multiple logistic regression analysis revealed that Hi and CRt were independently associated with L5-S1 disc degeneration, whereas Hr was a significant risk factor for L5-S1 endplate degeneration.

CONCLUSION

Anatomical and morphological characteristics of L5, such as smaller Hi, higher CRt and Hr, were associated with an increased risk of L5-S1 degeneration in patients after floating fusion. These findings may indicate the fusion level when addressing lower lumbar degenerative diseases and the concurrent radiographic degeneration of L5-S1.

MRI changes of adjacent segments after transforaminal lumbar interbody fusion (TLIF) and foraminal endoscopy: A case-control study

BACKGROUND

Intervertebral foramen endoscopy has developed rapidly, but compared with transforaminal lumbar interbody fusion (TLIF), the progress of degeneration is unknown. We aim to compare the changes of intervertebral disc and intervertebral foramen in adjacent segments after TLIF and endoscopic discectomy for patients with lumbar disc herniation (LDH).

METHODS

From 2014 to 2017, 87 patients who were diagnosed with single-level LDH and received surgery of TLIF (group T, n = 43) or endoscopic discectomy (group F, n = 44) were retrospectively analyzed. X-ray, MRI, CT and clinical symptoms were recorded before operation and at the last follow-up (FU). The neurological function was originally evaluated by the Japanese Orthopaedic Association (JOA) scores. Radiological evaluation included the height of intervertebral space (HIS), intervertebral foramen height (FH), intervertebral foramen area (FA), lumbar lordosis (CA) and intervertebral disc degeneration Pfirrmann scores.

RESULTS

There was no significant difference in baseline characteristics, JOA improvement rate, reoperation rate and complications between the two groups. The age, average blood loss, average hospital stays and average operation time in group F were lower than those in group T. During the last FU, HIS, CA and FA decreased in both groups, and the changes in group T were more significant than those in group F (P < .05). There was no significant difference in FH changes between the two groups (P > .05).

CONCLUSION

Both TLIF and endoscopic surgery can achieve good results in the treatment of LDH, but the risk of lumbar disc height loss and intervertebral foramina reduction in the adjacent segment after endoscopic surgery is lower.

Demographic, clinical, and operative risk factors associated with postoperative adjacent segment disease in patients undergoing lumbar spine fusions: a systematic review and meta-analysis

BACKGROUND CONTEXT

Adjacent segment disease (ASD) is a potential complication following lumbar spinal fusion.

PURPOSE

This study aimed to demonstrate the demographic, clinical, and operative risk factors associated with ASD development following lumbar fusion.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

PATIENT SAMPLE

We identified 35 studies that reported risk factors for ASD, with a total number of 7,374 patients who had lumbar spine fusion.

OUTCOME MEASURES

We investigated the demographic, clinical, and operative risk factors for ASD after lumbar fusion.

METHODS

A literature search was done using PubMed, Embase, Medline, Scopus, and the Cochrane library databases from inception to December 2019. The methodological index for non-randomized studies (MINORS) criteria was used to assess the methodological quality of the included studies. A meta-analysis was done to calculate the odds ratio (OR) with the 95% confidence interval (CI) for dichotomous data and mean difference (MD) with 95% CI for continuous data.

RESULTS

Thirty-five studies were included in the qualitative analysis, and 22 studies were included in the meta-analyses. The mean quality score based on the MINORS criteria was 12.4±1.9 (range, 8-16) points. Significant risk factors included higher preoperative body mass index (BMI) (mean difference [MD]=1.97 kg/m²; 95% confidence interval [CI]=1.49-2.45; p<.001), floating fusion (Odds ratio [OR]=1.78; 95% CI=1.32-2.41; p<.001), superior facet joint violation (OR=10.43; 95% CI=6.4-17.01; p<.001), and decompression outside fusion construct (OR=1.72; 95% CI=1.25-2.37; p<.001).

CONCLUSIONS

The overall level of evidence was low to very low. Higher preoperative BMI, floating fusion, superior facet joint violation, and decompression outside fusion construct are significant risk factors of development of ASD following lumbar fusion surgeries.

Chiropractic Nimmo Receptor-Tonus Technique and McKenzie Self-Therapy Program in the Management of Adjacent Segment Disease: A Case Report

Objective

The objective of the present study objective was to describe adjacent segment disease (ASD) from a chiropractic management prospective and subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.

Clinical Features

A 44-year-old woman had a history of lumbar stabilization revision operation by pedicle screw fixation for spondylolisthesis. Her intractable back pain episodes, which were diagnosed as ASD, began shortly after this surgery. At presentation, she was taking pregabalin 75 mg 2 times a day for postoperative neuropathic pain without any pain relief. Clinical testing revealed myofascial tender points reproducing the pain.

Intervention and Outcome

After taking the case history and performing a physical examination, the patient was managed with chiropractic Nimmo receptor-tonus technique in combination with McKenzie exercises. Nimmo was applied by manually pressing on clinically relevant points for 5 to 15 seconds in 11 visits over 3 weeks. The patient by herself did McKenzie exercises 5 to 10 times a day for 10 to 12 repetitions over 2 months. After 3 weeks of therapy, visual analog scale and Oswestry Disability Index scores were improved. Furthermore, because of the amelioration of the patient's symptoms, her neurosurgeon successfully discontinued pregabalin 75 mg 2 times a day without negative consequences to care.

Conclusion

As far as the authors are aware, there is currently no published case of ASD care in chiropractic literature. Our rehabilitative management received a favorable response. It can be hypothesized that it offers a perspective that informs improved patient care.

Current incidence of adjacent segment pathology following lumbar fusion versus motion-preserving procedures: a systematic review and meta-analysis of recent projections

BACKGROUND CONTEXT

Lumbar fusion has shown to be an effective surgical management option when indicated, improving patient outcomes and functional status. However, concerns of adjacent segment pathology (ASP) due to reduced mobility at the operated segment have fostered the emergence of motion-preserving procedures (MPP).

PURPOSE

To assess rates of radiographic adjacent segment degeneration (ASDeg) and symptomatic adjacent segment disease (ASDis) as well as reoperation rates due to ASP in patients who have undergone lumbar fusion compared to motion-preservation for degenerative disorders.

STUDY DESIGN

Systematic Review and Meta-Analysis.

METHODS

Following PRISMA guidelines, a systematic review and meta-analysis was conducted to find current (1/2012-12/2019) retrospective cohort studies and randomized controlled trials evaluating rates of ASDeg, ASDis, and reoperations due to lumbar ASP.

RESULTS

A total of 1,751 patients (791 underwent fusion surgery and 960 motion-preserving procedures) in 19 publications were included in the final analysis. Overall incidence rates of ASDeg, ASDis, and reoperation rates were 27.8%, 7.6%, and 4.6%, respectively. Results showed no significant difference between the lumbar fusion versus MPP cohorts in incidence of ASDeg (36.4% vs. 19.2%, p: 0.06), ASDis (10.7% vs. 4.42%, p: 0.25), or reoperation due to ASP (7.40% vs. 1.80%, p: 0.19). Fixed-effects analysis revealed patients who underwent MPP had significantly lower odds of ASDeg (OR: 2.57, CI: 1.95, 3.35, p<.05) and reoperations (OR: 3.18, CI: 1.63, 6.21, p<.05) compared to lumbar fusion patients.

CONCLUSIONS

This meta-analysis revealed no statistically significant difference in incidence of ASDeg, ASDis, or reoperations due to ASP for patients after lumbar fusion versus MPP. Weighted analysis, however, showed that MPP patients had significantly lower odds of ASDeg and reoperations due to ASP. While previous studies have established the biomechanical efficacy of MPP on cadaveric models, further high-quality studies are required to evaluate the long-term consequences of these procedures on patient-reported outcomes, postoperative complications, and associated inpatient/outpatient costs.

Adjacent segment disease after posterior lumbar instrumentation surgery for degenerative disease: Incidence and risk factors

PURPOSE

To identify risk factors for occurrence of symptomatic adjacent segment disease (ASD) after posterior lumbar instrumentation surgery.

METHODS

This retrospective study evaluated 630 patients who underwent posterior lumbar transpedicular instrumentation for degenerative lumbar disorders between April 2008 and April 2012. On the basis of developing ASD at follow-up, patients were categorized into two groups: the ASD group and the non-ASD (N-ASD) group. These two groups were compared for patient characteristics, surgical variables, and radiographic parameters to investigate the possible predictive factors of ASD.

RESULTS

Of the 630 individuals participated in the study, 76 (12.1%) patients had ASD. Mean and standard deviation of age were 61.37 ± 4.12 years for the ASD group and 62.37 ± 3.9 for the N-ASD group ( p = 0.79). The average follow-up period was 51 ± 2.2 months in the ASD group and 52 ± 2.3 months in the N-ASD group ( p = 0.691). There were no significant differences between the two groups in terms of gender, diabetes mellitus (DM), hypertension, smoking, and osteoporosis, with all p > 0.05. The logistic regression analysis demonstrated that higher preoperative body mass index (BMI; odds ratio (OR) 1.233, p = 0.005), preoperative disc degeneration (OR 1.033, p = 0.024), decreased postoperative lumbar lordosis (OR 3.080, p = 0.011), fusion at more than four levels (OR 4.280, p = 0.014), and intraoperative superior facet joint violation (OR 7.480, p = 0.009) were independently associated with ASD.

CONCLUSIONS

Patients with higher preoperative BMI, preoperative disc degeneration, decreased postoperative lumbar lordosis, fusion at more than four levels, and intraoperative superior facet joint violation have a statistically significant increased risk of developing ASD.

Incidence and risk factors of reoperation in patients with adjacent segment disease: A meta-analysis

Study Design:

This was a systematic review of the literature and meta-analysis.

Objective:

The objective of this study was to evaluate the current literature regarding the risk factors contributing to reoperation due to adjacent segment disease (ASD).

Summary of Background Data:

ASD is a broad term referring to a variety of complications which might require reoperation. Revision spine surgery is known to be associated with poor clinical outcomes and high rate of complications. Unplanned reoperation has been suggested as a quality marker for the hospitals.

Materials and Methods:

An electronic search was conducted using PubMed. A total of 2467 articles were reviewed. Of these, 55 studies met our inclusion criteria and included an aggregate of 1940 patients. Data were collected pertaining to risk factors including age, sex, fusion length, lumbar lordosis, body mass index, pelvic incidence, sacral slope, pelvis tilt, initial pathology, type of fusion procedure, floating versus sacral or pelvic fusion, presence of preoperative facet or disc degeneration at the junctional segment, and sagittal orientation of the facets at the junctional segment. Analysis of the data was performed using Comprehensive Meta-Analysis software (Biostat, Inc.).

Results:

The overall pooled incidence rate of reoperation due to ASD from all included studies was 0.08 (confidence interval: 0.065–0.098). Meta-regression analysis demonstrated no significant interaction between age and reoperation rate (P = 0.48). A comparison of the event rates between males and females demonstrated no significant difference between male and female reoperation rates (P = 0.58). There was a significantly higher rate of ASD in patients with longer fusion constructs (P = 0.0001).

Conclusions:

We found that 8% of patients in our included studies required reoperation due to ASD. Our analysis also revealed that longer fusion constructs correlated with a higher rate of subsequent revision surgery. Therefore, the surgeon should limit the number of fusion levels if possible to reduce the risk of future reoperation due to ASD.

Level of evidence:

IV

Preoperative Risk Factors for Adjacent Segment Degeneration after Two-Level Floating Posterior Fusion at L3-L5

Introduction

The aims of this study were to investigate how adjacent segment degeneration (ASD) occurs at the proximal and distal segments after L3-L5 fusion surgery, namely, floating fusion, and to identify the risk factors for ASD in patients who undergo this surgery.

Methods

Fifty patients who underwent floating fusion surgery at vertebrae L3-L5 and developed ASD were enrolled. The following parameters were evaluated: body mass index (BMI), diabetes status, dialysis status, lumbar lordosis, segmental lordosis between the L2 upper endplate and the L3 lower endplate, disc height, Cobb's angle, apical vertebral rotation using the Nash and Moe classification method, preoperative disc degeneration, surgical procedures, and the upper instrumented vertebra (UIV) tilt angle. The UIV tilt angle was defined as positive when the anterior side was directed caudally.

Results

Twenty-two (44%) of the 50 patients showed cephalad radiographic ASD (RASD) and 5 patients (10%) showed caudad RASD. Clinically symptomatic ASD was found at L2-L3 in 4 patients (8%) and at L5-S1 in 2 patients (4%). All the patients with clinically symptomatic cephalad ASD underwent revision procedures for radiculopathy or claudication because of degenerative pathology at L3-L4. Multivariate regression analysis showed a significant association of the absolute value of UIV tilt angle (mean |UIV tilt|) with cephalad RASD (odds ratio 1.09, p = 0.038). Receiver-operating characteristic curve analysis showed a significant association of |UIV tilt| >10.3° with RASD (sensitivity 67.9%, specificity 77.3%, area under the curve [AUC] 0.675).

Conclusions

RASD was more likely to occur at the adjacent segment on the cephalad side than at the adjacent segment on the caudad side after two-segment floating fusion of L3-L5. A preoperative UIV tilt angle >10° or UIV tilt < -10° was a risk factor for RASD.

Adjacent Segment Disease After Single Segment Posterior Lumbar Interbody Fusion for Degenerative Spondylolisthesis: Minimum 10 Years Follow-up

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to investigate the incidence of adjacent segment disease (ASD) at 2, 5, and 10 years after primary posterior lumbar interbody fusion (PLIF), and clinical features of ASD.

SUMMARY OF BACKGROUND DATA

Few reports have examined ASD after PLIF with more than 10 years of follow-up. Furthermore, no reports have examined limited conditions of preoperative pathology, fusion segment, and fusion method with long follow-up.

METHODS

Data were reviewed for 128 patients who underwent single-segment PLIF for L4 degenerative spondylolisthesis and could be followed for at least 10 years. Mean age at the time of surgery was 63 years, and mean follow-up was 12.4 years. Follow-up rate was 62.4%. ASD was defined as radiological ASD (R-ASD), radiological degeneration adjacent to the fusion segment by plain X-rays and magnetic resonance imaging (MRI); symptomatic ASD (S-ASD), a symptomatic condition due to neurological deterioration at the adjacent segment degeneration; and operative ASD (O-ASD), S-ASD requiring revision surgery.

RESULTS

Incidences of each ASD at 2, 5, and 10 years after primary PLIF were 19%, 49%, and 75% for R-ASD, 6%, 14%, and 31% for S-ASD, and 5%, 9%, and 15% for O-ASD, respectively. O-ASD incidence was 24% at final follow-up. O-ASD peak was bimodal, at 2 and 10 years after primary PLIF. O-ASD was mainly observed at the cranial segment (77%), followed by the caudal segment (13%) and both cranial and caudal segments (10%). With respect to O-ASD pathology, degenerative spondylolisthesis was observed in 52%, spinal stenosis in 39%, and disc herniation in 10%.

CONCLUSION

Incidences of R-ASD, S-ASD, and O-ASD at 10 years after primary PLIF were 75%, 31%, and 15%, respectively. With respect to O-ASD pathology, degenerative spondylolisthesis at the cranial segment was the most frequent.

LEVEL OF EVIDENCE

4.

ANALYSIS OF POSTOPERATIVE OUTCOMES OF DEGENERATIVE DISEASES OF THE LUMBOSACRAL JUNCTION

ABSTRACT Objective: The article presents an analysis of the clinical efficacy and causes of unsatisfactory outcomes of surgical treatment in patients with degenerative diseases of the lumbosacral junction of the spine. Methods: Patients were allocated to one of three groups, depending on the method of surgical intervention on the lumbosacral junction: 1) (n=352) - operated by the method of microsurgical discectomy; 2) (n=83) - operated with the use of artificial IVD prostheses; 3) (n = 183) - operated with the use of interbody fusion and posterior rigid stabilization. To investigate the causes of unsatisfactory outcomes, a correlation analysis was conducted of long-term clinical outcomes with preoperative instrumental parameters in the operated segment, surgical tactics used, and the development of complications. Results: It is determined that long-term “good” clinical outcomes are associated with individual preoperative parameters of the lumbosacral junction of the spine - linear displacement, sagittal angulation, height of the interbody space, degree of IVD degeneration by ADC. Conclusion: In degenerative diseases of the lumbosacral junction of the spine, the detailed analysis of long-term clinical outcomes enable the identification of the causes that affect the development of unsatisfactory outcomes, which are individual morphostructural changes in the lower lumbar segment: the amplitude of the segmental angle, the angle of the lumbar lordosis, the degree of linear displacement of the vertebrae, the height of the interbody space, and ADC. Complex clinical and instrumental analysis enabled us to determine possible surgical tactics. Level of Evidence II; Prognostic Studies— Investigating the Effect of a Patient Characteristic on the Disease Outcome.

Revision Surgery for Short Segment Fusion Influences Postoperative Low Back Pain and Lower Extremity Pain: A Retrospective Single-Center Study of Patient-Based Evaluation

Introduction

Patients treated with revision surgery after lumbar decompression with fusion typically have persistent low back pain and lower extremity numbness compared with patients treated with only primary surgery. No well-designed study has investigated the persistence and degree of pain after revision surgery following instrumented operation. The purpose of this study is to compare residual pain among patients who underwent reoperation and those who underwent only primary surgery for lumbar degenerative disorder using patient-based evaluation.

Methods

We reviewed 350 consecutive patients (143 men, 207 women, mean age 63 years) treated with primary lumbar instrumented surgery between October 2010 and February 2014 at our institution and followed up for ≥2 years postoperatively. Patients were categorized into three groups based on number of levels fused: 1-segment, 2-segment, and ≥3-segment fusion (1F, 2F, and ≥3F groups, respectively). We used the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and visual analog scales (VASs) for low back pain and lower extremity pain to evaluate pain intensity pre- and postoperatively.

Results

Salvage surgery for late-phase complications was required in 5 cases (2.4%), 6 cases (11.3%), and 11 cases (12.1%) in the 1F, 2F, and ≥3F groups, respectively. In the 1F and 2F groups, patients treated with revision surgery had unsatisfactory improvement in the pain domain of JOABPEQ and VASs for low back pain and lower extremity pain compared with patients with only primary short fusion surgery. The ≥3F group showed no significant differences between patients who underwent reoperation and those who underwent only primary surgery.

Conclusion

Low back pain and lower extremity pain often persist after revision surgery in patients treated with short fusion (≤2-segment) operation. We need to follow pain states in such patients.

Osteopathic Manipulative Treatment for the Management of Adjacent Segment Pathology

Adjacent segment pathology is an adverse effect of spinal fusion that precipitates accelerated spinal degenerative changes at vertebral segments contiguous with the fused vertebrae. The accelerated degeneration related to ASP can be challenging to manage, as it can lead to conditions such as radiculopathy and can create the need for reoperation. In the present case, a 50-year-old woman with a previous spinal fusion presented with a 1-year history of progressive low back pain, lumbar radiculopathy, and sciatica. Osteopathic manipulative treatment was used to manage her pain, and the patient reported that the treatment provided long-term resolution of her sciatica symptoms. This case demonstrates an effective use of osteopathic manipulative treatment in the conservative management of lumbar radiculopathy related to adjacent segment pathology.

Adjacent Disc Stress Following Floating Lumbar Spine Fusion: A Finite Element Study

STUDY DESIGN

Experimental study.

PURPOSE

The study aimed to develop a finite element (FE) model to determine the stress on the discs adjacent to the fused segment following different types of floating lumbar spinal fusions.

OVERVIEW OF LITERATURE

The quantification of the adjacent disc stress following different types of floating lumbar fusions has not been reported. The magnitude of the stress on the discs above and below the floating fusion remains unknown.

METHODS

A computer-aided engineering-based approach using implicit FE analysis was employed to assess the stress on the lumbar discs above and below the floating fusion segment (L4-L5) following anterior and posterior lumbar spine fusions at one, two, and three levels (with and without instrumentation).

RESULTS

Both discs suprajacent and infrajacent to the floating fusion experienced increased stress, but the suprajacent disc experienced relatively high stress level. Instrumentation increased the stress on the discs suprajacent and infrajacent to the floating fusion, but the magnitude of stress on the suprajacent disc remained relatively high.

CONCLUSIONS

The FE model was employed under similar loading and boundary conditions to provide quantitative data, which will be useful for clinicians to understand the probable long-term effects of floating fusions.

[Spinal column: implants and revisions]

Non-fusion spinal implants are designed to reduce the commonly occurring risks and complications of spinal fusion surgery, e.g. long duration of surgery, high blood loss, screw loosening and adjacent segment disease, by dynamic or movement preserving approaches. This principle could be shown for interspinous spacers, cervical and lumbar total disc replacement and dynamic stabilization; however, due to the continuing high rate of revision surgery, the indications for surgery require as much attention and evidence as comparative data on the surgical technique itself.

Posterior lumbar dynamic stabilization instead of arthrodesis for symptomatic adjacent-segment degenerative stenosis: description of a novel technique

OBJECTIVE The development of symptomatic adjacent-segment disease (ASD) is a well-recognized consequence of lumbar fusion surgery. Extension of a fusion to a diseased segment may only lead to subsequent adjacent-segment degeneration. The authors report the use of a novel technique that uses dynamic stabilization instead of arthrodesis for the surgical treatment of symptomatic ASD following a prior lumbar instrumented fusion. METHODS A cohort of 28 consecutive patients was evaluated who developed symptomatic stenosis immediately adjacent to a previous lumbar instrumented fusion. All patients had symptoms of neurogenic claudication refractory to nonsurgical treatment and were surgically treated with decompression and dynamic stabilization instead of extending the fusion construct using a posterior lumbar dynamic stabilization system. Preoperative symptoms, visual analog scale (VAS) pain scores, and perioperative complications were recorded. Clinical outcome was gauged by comparing VAS scores prior to surgery and at the time of last follow-up. RESULTS The mean follow-up duration was 52 months (range 17-94 months). The mean interval from the time of primary fusion surgery to the dynamic stabilization surgery was 40 months (range 10-96 months). The mean patient age was 51 years (range 29-76 years). There were 19 (68%) men and 9 (32%) women. Twenty-three patients (82%) presented with low-back pain at time of surgery, whereas 24 patients (86%) presented with lower-extremity symptoms only. Twenty-four patients (86%) underwent operations that were performed using single-level dynamic stabilization, 3 patients (11%) were treated at 2 levels, and 1 patient underwent 3-level decompression and dynamic stabilization. The most commonly affected and treated level (46%) was L3-4. The mean preoperative VAS pain score was 8, whereas the mean postoperative score was 3. No patient required surgery for symptomatic degeneration rostral to the level of dynamic stabilization during the follow-up period. CONCLUSIONS The use of posterior lumbar dynamic stabilization may offer a valid and safe option for the management of patients who develop ASD rostral to a previously instrumented arthrodesis. The technique may serve as an alternative to multilevel arthrodesis in this patient population. By implanting a dynamic stabilization device instead of an extension of a rigid construct, this might translate into a reduction in the development of yet another level of ASD.

Incidence of Adjacent Segment Disease Requiring Reoperation After Lumbar Laminectomy Without Fusion

BACKGROUND:

Adjacent segment disease (ASD) has not been described after laminectomy without fusion.

OBJECTIVE:

To determine the incidence of ASD after a 1- or 2-level lumbar laminectomy.

METHODS:

We retrospectively reviewed medical records of all patients who underwent 1- or 2-level, bilateral lumbar laminectomy without fusion for degenerative spinal disease (all follow-up ≥1 year). ASD was defined as clinical and/or radiographic evidence of degenerative spinal disease that required reoperation at the level above or below the index laminectomy.

RESULTS:

Of the 398 patients, the incidence of ASD requiring reoperation was 10%. The 39 ASD cases were almost equally distributed at L2-L3 (31%), L3-L4 (26%), and L5-S1 (31%), and to a lesser extent at L4-L5 (15%) (P = .51). The ASD incidences of 10% and 9% were equivalent after a 1- and 2-level laminectomy, respectively (P = .76). Rostral ASD was statistically more common than caudal ASD after both the 1- (P &lt; .001) and 2- (P &lt; .001) level laminectomy. Of the 39 ASD cases, 95% required laminectomy, 26% discectomy, and 49% fusion. Average time to ASD was 4 years. After a Kaplan-Meier analysis, time to reoperation for ASD was equivalent among the 1- and 2-level laminectomy cohorts (log-rank test, P = .13).

CONCLUSION:

The cumulative incidence of ASD requiring reoperation was 10% over a mean of 4 years. Both the 1- and 2-level laminectomy cohorts experienced equivalent incidences and rates of ASD. Of the 39 operations for ASD, about half required a fusion.

Clinical and surgical outcomes after lumbar laminectomy: An analysis of 500 patients

Background:

The objective of this study is to determine the clinical and surgical outcomes following lumbar laminectomy.

Methods:

We retrospectively reviewed medical records of neurosurgical patients who underwent first-time, bilateral, 1-3 level laminectomies for degenerative lumbar disease. Patients with discectomy, complete facetectomy, and fusion were excluded.

Results:

Five hundred patients were followed for an average of 46.79 months. Following lumbar laminectomy, patients experienced statistically significant improvement in back pain, neurogenic claudication, radiculopathy, weakness, and sensory deficits. The rate of intraoperative durotomy was 10.00%; however, 1.60% experienced a postoperative cerebrospinal fluid leak. The risk of experiencing at least one postoperative complication with a lumbar laminectomy was 5.60%. Seventy-two patients (14.40%) required reoperations for progression of degenerative disease over a mean of 3.40 years. The most common symptoms prior to reoperation included back pain (54.17%), radiculopathy (47.22%), weakness (18.06%), sensory deficit (15.28%), and neurogenic claudication (19.44%). The relative risk of reoperation for patients with postoperative back pain was 6.14 times higher than those without postoperative back pain (P < 0.001). Of the 72 patients undergoing reoperations, 55.56% underwent decompression alone, while 44.44% underwent decompression and posterolateral fusions. When considering all-time reoperations, the lifetime risk of requiring a fusion after a lumbar laminectomy based on this study (average follow-up of 46.79 months) was 8.0%.

Conclusion:

Patients experienced statistically significant improvements in back pain, neurogenic claudication, radiculopathy, motor weakness, and sensory deficit following lumbar laminectomy. Incidental durotomy rate was 10.00%. Following a first-time laminectomy, the reoperation rate was 14.4% over a mean of 3.40 years.