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Park S, Hwang CJ, Lee DH, Kim NY, Nam HW, Kang HW, Lee CS, Ok CH, Cho JH. Risk factors of revision operation and early revision for adjacent segment degeneration after lumbar fusion surgery: a case-control study. Spine J 2024:S1529-9430(24)00183-9. [PMID: 38663482 DOI: 10.1016/j.spinee.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND CONTEXT Adjacent segment degeneration (ASD) following lumbar fusion operation is common and can occur at varying timepoints after index surgery. An early revision operation for ASD, however, signifies a short symptom-free period and might increase the risk of successive surgeries. PURPOSE We aimed to elucidate the overall risk factors associated with revision surgeries for ASD with distinct attention to early revisions. STUDY DESIGN/SETTING Retrospective, case-control study. PATIENT SAMPLE The study included 86 patients who underwent revision operations for ASD after lumbar fusion in the revision group and 166 patients who did not for at least 5 years after index surgery. OUTCOME MEASURES Sagittal parameters, Pfirrmann grading, facet degeneration grading, and disc space height (DSH) of adjacent segments were assessed. METHODS Revision operations within 5 years postsurgery were defined as early revision. We compared the revision and no-revision groups as well as the early- and late-revision groups. RESULTS The revision group demonstrated a significantly greater preoperative C7-S1 sagittal vertical axis (SVA) (p=.001), postoperative C7-S1 SVA (p<.001), and postoperative pelvic incidence (PI)-lumbar lordosis (LL) (p<.001) than those in the no-revision group. Preoperative DSH of the proximal adjunct segment (p=.001), postoperative PI-LL (p=.014), and postoperative C7-S1 SVA (p=.037) exhibited significant association with ASD in logistic regression analysis. The early-revision group had a significantly higher patient age (p=.001) and a greater number of levels fused (p=.030) than those in the late-revision group. Multivariate Cox regression analysis demonstrated that old age (p=.045), a significant number of levels fused (p=.047), and a narrow preoperative DSH of the proximal adjacent level (p=.011) were risk factors for early revision. CONCLUSIONS Postoperative sagittal imbalance, including significant PI-LL and C7-S1 SVA were risk factors for revision operation for ASD but not for early revision. These factors are likely to affect the long-term risk of revision operation due to ASD and thus are not considered risk factors for early revision. Narrow DSH of the proximal adjacent level increased the risks of both revision and early revision surgeries. Moreover, old age and a significant number of levels fused further increased the risk for early revision for ASD.
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Affiliation(s)
- Sehan Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Nam Yeop Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Hyun Wook Nam
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Hyun Wook Kang
- Department of Spine Surgery, St.Peter's Hospital, 2649, Nambusunhwan-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Choon Sung Lee
- Department of Spine Surgery, St.Peter's Hospital, 2649, Nambusunhwan-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Cha Hyeong Ok
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-2-dong, Seoul, Republic of Korea.
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Herrington BJ, Fernandes RR, Urquhart JC, Rasoulinejad P, Siddiqi F, Bailey CS. L3-L4 Hyperlordosis and Decreased Lower Lumbar Lordosis Following Short-Segment L4-L5 Lumbar Fusion Surgery is Associated With L3-L4 Revision Surgery for Adjacent Segment Stenosis. Global Spine J 2023:21925682231191414. [PMID: 37485611 DOI: 10.1177/21925682231191414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective cohort. OBJECTIVES Reoperation at L3-L4 for adjacent segment disease (ASD) is common after L4-L5 spine fusion. L4-S1 lower lumbar lordosis (LLL) accounts for the majority of global lumbar lordosis (GLL) and is modifiable during surgery. We sought to determine if a reduction in LLL leads to an increase in L3-L4 focal lumbar lordosis (L3-L4 FLL) and resulting risk of ASD at L3-L4. METHODS We reviewed the records of a prospective cohort with lumbar spinal stenosis who underwent L4-L5 or L4-L5-S1 fusion between 2006 and 2012. Radiographic parameters-GLL, LLL, L3-L4 FLL, upper lumbar lordosis, lordosis distribution index, pelvic tilt, and pelvic incidence-were extracted from preoperative and postoperative lumbar spine radiographs. Statistical comparisons were made between those who underwent revision for post-fusion adjacent level stenosis at L3-L4 (REVISION) and those who did not (NO REVISION). RESULTS Inclusion criteria were met by 104 patients. The REVISION cohort included 19 individuals. No significant differences in baseline demographics or operative details for the index procedure were found between groups. Postoperatively, when compared to the NO REVISION cohort, the REVISION cohort had a decrease in LLL (-2.6° vs + 1.5°, P = .011) and LDI (-5.1% vs + 1.3%, P = .039), and an increase in L3-L4 FLL (+2.6° vs -.6°, P = .001). CONCLUSIONS A reduction in LLL and compensatory increase in L3-L4 FLL after initial lower lumbar fusion surgery resulted in more reoperation at L3-L4 for post-fusion adjacent level spinal stenosis.
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Affiliation(s)
- Brandon J Herrington
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Renan R Fernandes
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jennifer C Urquhart
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Center, London, ON, Canada
| | - Parham Rasoulinejad
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Center, London, ON, Canada
| | - Fawaz Siddiqi
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Center, London, ON, Canada
| | - Christopher S Bailey
- Combined Neurosurgical and Orthopaedic Spine Program, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Center, London, ON, Canada
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Agarwal N, Aabedi AA, Chan AK, Letchuman V, Shabani S, Bisson EF, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Haid RW, Chou D, Mummaneni PV. Leveraging machine learning to ascertain the implications of preoperative body mass index on surgical outcomes for 282 patients with preoperative obesity and lumbar spondylolisthesis in the Quality Outcomes Database. J Neurosurg Spine 2023; 38:182-191. [PMID: 36208428 DOI: 10.3171/2022.8.spine22365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prior studies have revealed that a body mass index (BMI) ≥ 30 is associated with worse outcomes following surgical intervention in grade 1 lumbar spondylolisthesis. Using a machine learning approach, this study aimed to leverage the prospective Quality Outcomes Database (QOD) to identify a BMI threshold for patients undergoing surgical intervention for grade 1 lumbar spondylolisthesis and thus reliably identify optimal surgical candidates among obese patients. METHODS Patients with grade 1 lumbar spondylolisthesis and preoperative BMI ≥ 30 from the prospectively collected QOD lumbar spondylolisthesis module were included in this study. A 12-month composite outcome was generated by performing principal components analysis and k-means clustering on four validated measures of surgical outcomes in patients with spondylolisthesis. Random forests were generated to determine the most important preoperative patient characteristics in predicting the composite outcome. Recursive partitioning was used to extract a BMI threshold associated with optimal outcomes. RESULTS The average BMI was 35.7, with 282 (46.4%) of the 608 patients from the QOD data set having a BMI ≥ 30. Principal components analysis revealed that the first principal component accounted for 99.2% of the variance in the four outcome measures. Two clusters were identified corresponding to patients with suboptimal outcomes (severe back pain, increased disability, impaired quality of life, and low satisfaction) and to those with optimal outcomes. Recursive partitioning established a BMI threshold of 37.5 after pruning via cross-validation. CONCLUSIONS In this multicenter study, the authors found that a BMI ≤ 37.5 was associated with improved patient outcomes following surgical intervention. These findings may help augment predictive analytics to deliver precision medicine and improve prehabilitation strategies.
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Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Alexander A Aabedi
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Vijay Letchuman
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Saman Shabani
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin T Foley
- 5Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, Tennessee
| | - Christopher I Shaffrey
- Departments of6Neurosurgery and
- 7Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Eric A Potts
- 8Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Mark E Shaffrey
- 9Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Domagoj Coric
- 10Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 12Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Y Wang
- 13Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L Asher
- 10Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Michael S Virk
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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Xu Y, Fan P, Xu X, Jiang F, Zhang W, Yin X, Liu H, Wang P, Wang Y. [Study of modified subcutaneous lumbar spine index as a predictor for short-term effectiveness in transforaminal lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:878-885. [PMID: 34308597 DOI: 10.7507/1002-1892.202101154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the value of modified subcutaneous lumbar spine index (MSLSI) as a predictor for short-term effectiveness of transforaminal lumbar interbody fusion (TLIF) in treatment of lumbar degenerative disease (LDD). Methods Between February 2014 and October 2019, 450 patients who were diagnosed as LDD and received single-segment TLIF were included in the study. Based on the MSLSI measured by preoperative lumbar MRI, the patients were sorted from small to large and divided into three groups ( n=150). The MSLSI of group A was 0.11-0.49, group B was 0.49-0.73, and group C was 0.73-1.88. There was no significance in gender, age, disease duration, diagnosis, surgical segment, and improved Charlson comorbidity index between groups ( P>0.05). There were significant differences in the subcutaneous adipose depth of the L 4 vertebral body and body mass index (BMI) between groups ( P<0.05). The operation time, intra-operative blood loss, length of incision, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, total drainage volume, antibiotic use time after operation, walking exercise time after operation, hospital stay, the incidences of surgical or non-surgical complications in the three groups were compared. Pearson correlation analysis was used to analyze the correlation between MSLSI and BMI, and partial correlation analysis was used to study the relationship between MSLSI, BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L 4 vertebral body and complications. The Receiver Operating Characteristic (ROC) curve was used to evaluate the value of SLSI and MSLSI in predicting the occurrence of complications after TLIF in treatment of LDD. Results There was no significant difference in operation time, length of incision, antibiotic use time after operation, walking exercise time after operation, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, and total drainage volume between groups ( P>0.05). The amount of intra-operative blood loss in group C was higher than that in groups A and B, and the hospital stay was longer than that in group B, with significant differences ( P<0.05). Surgical complications occurred in 22 cases (14.7%), 25 cases (16.7%), and 39 cases (26.0%) of groups A, B, and C, respectively. There was no significant difference in the incidence between groups ( χ 2=0.826, P=0.662). The incidences of nerve root injury and wound aseptic complications in group C were higher than those in groups A and B, and the incidence of nerve root injury in group B was higher than that in group A, with significant differences ( P<0.05). There were 13 cases (8.7%), 7 cases (4.7%), and 11 cases (7.3%) of non-surgical complications in groups A, B, and C, respectively, with no significant difference ( χ 2=2.128, P=0.345). There was no significant difference in the incidences of cardiovascular complications, urinary system complications, central system complications, and respiratory system complications between groups ( P>0.05). There was a correlation between MSLSI and BMI in 450 patients ( r=0.619, P=0.047). Partial correlation analysis showed that MSLSI was related to wound aseptic complications ( r=0.172, P=0.032), but not related to other surgical and non-surgical complications ( P>0.05). There was no correlation between BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L 4 vertebral body and surgical and non-surgical complications ( P>0.05). ROC curve analysis showed that the area under ROC curve (AUC) of MSLSI was 0.673 (95%CI 0.546-0.761, P=0.025), and the AUC of SLSI was 0.582 (95%CI 0.472-0.693, P=0.191). Conclusion MSLSI can predict the short-term effectiveness of TLIF in treatment of LDD. Patients with high MSLSI suffer more intra-operative blood loss, longer hospital stay, and higher incidence of nerve root injury and postoperative incision complications.
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Affiliation(s)
- Yuzhu Xu
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Pan Fan
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xuanfei Xu
- Department of Nulear Medicine, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Feng Jiang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Wei Zhang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiangjie Yin
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hang Liu
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Peiyang Wang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yuntao Wang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
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