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Zhou K, Ji L, Pang S, Tang Y, Liu C. Predictive nomogram of cage nonunion after anterior cervical discectomy and fusion: A retrospective study in a spine surgery center. Medicine (Baltimore) 2022; 101:e30763. [PMID: 36181102 PMCID: PMC9524884 DOI: 10.1097/md.0000000000030763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The cage nonunion may cause serious consequences, including recurrent pain, radiculopathy, and kyphotic deformity. The risk factors for nonunion following anterior cervical discectomy and fusion (ACDF) are controversial. The aim of the study is to investigate the risk factors for nonunion in cervical spondylotic cases after ACDF. We enrolled 58 and 692 cases in the nonunion and union group respectively and followed up the cases at least 6 months. Patient demographic information, surgical details, cervical sagittal parameters, and the serum vitamin D level were collected. A logistic regression was performed to determine the independent predictors for nonunion, which were used for establishing a nomogram. In order to estimate the reliability and the net benefit of nomogram, we applied a receiver operating characteristic curve analysis, calibration curves and plotted decision curves. Using the multivariate logistic regression, we found that age (odds ratio [OR] = 1.16, P < .001), smoking (OR = 3.41, P = .001), angle of C2 to C7 (OR = 1.53, P < .001), number of operated levels (2 levels, OR = 0.42, P = .04; 3 levels, OR = 1.32, P = .54), and serum vitamin D (OR = 0.81, P < .001) were all significant predictors of nonunion (Table 3). The area under the curve of the model training cohort and validation cohort was 0.89 and 0.87, respectively. The calibration curves showed that the predicted outcome fitted well to the observed outcome in the training cohort (P = .102,) and validation cohort (P = .125). The decision curves showed the nomogram had more benefits than the All or None scheme if the threshold probability is >10% and <100% in training cohort and validation cohort. We found that age, smoking, angle of C2 to C7, number of operated levels, and serum vitamin D were all significant predictors of nonunion.
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Affiliation(s)
- Kai Zhou
- Department of Trauma Surgery, The People’s Hospital of Dongying District, Dongying, Shandong Province, China
| | - Longfei Ji
- Department of Trauma Surgery, The People’s Hospital of Dongying District, Dongying, Shandong Province, China
| | - Shuwei Pang
- Department of Trauma Surgery, The People’s Hospital of Dongying District, Dongying, Shandong Province, China
| | - You Tang
- Department of Orthopaedics and Joint Surgery, Binzhou People’s Hospital, Dongying, Shandong Province, China
| | - Changliang Liu
- Department of Trauma Surgery, The People’s Hospital of Dongying District, Dongying, Shandong Province, China
- *Correspondence: Changliang Liu, Trauma Surgery, The People’s Hospital of Dongying District, No. 333 Jinan Road, Dongying City, Shandong Province, China (e-mail: )
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Tsagkaris C, Widmer J, Wanivenhaus F, Redaelli A, Lamartina C, Farshad M. The sitting vs standing spine. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 9:100108. [PMID: 35310424 PMCID: PMC8924684 DOI: 10.1016/j.xnsj.2022.100108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
Background Planning of surgical procedures for spinal fusion is performed on standing radiographs, neglecting the fact that patients are mostly in the sitting position during daily life. The awareness about the differences in the standing and sitting configuration of the spine has increased during the last years. The purpose was to provide an overview of studies related to seated imaging for spinal fusion surgery, identify knowledge gaps and evaluate future research questions. Methods A literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews (PRISMASc) was performed to identify reports related to seated imaging for spinal deformity surgery. A summary of the finding is presented for healthy individuals as well as patients with a spinal disorder and/or surgery. Results The systematic search identified 30 original studies reporting on 1) the pre- and postoperative use of seated imaging of the spine (n=12), 2) seated imaging of the spine for non - surgical evaluation (n=7) and 3) seated imaging of the spine among healthy individuals (12). The summarized evidence illuminates that sitting leads to a straightening of the spine decreasing thoracic kyphosis (TK), lumbar lordosis (LL), the sacral slope (SS). Further, the postural change between standing and sitting is more significant on the lower segments of the spine. Also, the adjacent segment compensates the needed postural change of the lumbar spine while sitting with hyperkyphosis. Conclusions The spine has a different configuration in standing and sitting. This systematic review summarizes the current knowledge about such differences and reveals that there is minimal evidence about their consideration for surgical planning of spinal fusion surgery. Further, it identifies gaps in knowledge and areas of further research.
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Affiliation(s)
- Christos Tsagkaris
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Jonas Widmer
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland.,Spine Biomechanics, Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | - Florian Wanivenhaus
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Andrea Redaelli
- GSpine4 - I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
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Pennicooke B, Santacatterina M, Lee J, Elowitz E, Kallus N. The effect of patient age on discharge destination and complications after lumbar spinal fusion. J Clin Neurosci 2021; 91:319-326. [PMID: 34373046 DOI: 10.1016/j.jocn.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
Age is an important patient characteristic that has been correlated with specific outcomes after lumbar spine surgery. We performed a retrospective cohort study to model the effect of age on discharge destination and complications after a 1-level or multi-level lumbar spine fusion surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar spinal fusion surgery from 2013 through 2017. Perioperative outcomes were compared across ages 18 to 90 using multivariable nonlinear logistic regressioncontrolling for preoperative characteristics. A total of 61,315 patients were analyzed, with patients over 70 having a higher risk of being discharged to an inpatient rehabilitation center and receiving an intraoperative or postoperative blood transfusion. However, the rates of the other complications and outcomes analyzed in this study were not significantly different as patients age. In conclusion, advanced-age affects the discharge destination after a one- or multi-level fusion and intraoperative/postoperative blood transfusion after a one-level fusion. However, age alone does not significantly affect the risk of the other complications and outcomes assessed in this study. This study will help guide preoperative discussion with advanced-aged patients who are considering a 1-level or multi-level lumbar spine fusion surgery.
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Affiliation(s)
- Brenton Pennicooke
- Department of Neurosurgery, Washington University in St. Louis, 660 South Euclid Ave, Campus Box 8057, St. Louis, MO 63110 USA
| | - Michele Santacatterina
- Department of Biostatistics and Bioinformatics, The Biostatistics Center, The George Washington University, 6110 Executive Boulevard, Suite 750, Rockville, MD 20852, USA
| | - Jennifer Lee
- Department of Neurosurgery, Washington University in St. Louis, 660 South Euclid Ave, Campus Box 8057, St. Louis, MO 63110 USA
| | - Eric Elowitz
- Department of Neurosurgery, Weill Cornell Medical College, 525 East 68th Street, Whitney 6, Box 99, New York, NY 10065, USA
| | - Nathan Kallus
- Department of Operations Research and Information Engineering, Cornell Tech, 2 West Loop Road, New York, NY 10044, USA
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Kim HJ, Dash A, Cunningham M, Schwab F, Dowdell J, Harrison J, Zaworski C, Krez A, Lafage V, Agarwal S, Carlson B, McMahon DJ, Stein EM. Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery. Bone 2021; 143:115731. [PMID: 33157283 PMCID: PMC9518007 DOI: 10.1016/j.bone.2020.115731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022]
Abstract
Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m2) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexander Dash
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Matthew Cunningham
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Frank Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - James Dowdell
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Jonathan Harrison
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Caroline Zaworski
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexandra Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Sanchita Agarwal
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States of America
| | - Brandon Carlson
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America.
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Lenz M, Mohamud K, Bredow J, Oikonomidis S, Eysel P, Scheyerer MJ. Comparison of Different Approaches in Lumbosacral Spinal Fusion Surgery: A Systematic Review and Meta-Analysis. Asian Spine J 2021; 16:141-149. [PMID: 33389967 PMCID: PMC8873994 DOI: 10.31616/asj.2020.0405] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/25/2020] [Indexed: 11/23/2022] Open
Abstract
We aimed to systematically review the literature to analyze the differences in posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and transforaminal lumbar interbody fusion (TLIF), focusing on the complications, risk factors, and fusion rate of each approach. Spinal fusion surgery is a well-established surgical procedure for a variety of indications, and different approaches developed. The various approaches and their advantages, as well as approach-related pathology and complications, are well investigated in spinal surgery. Focusing only on lumbosacral fusion, the comparative studies of different approaches remain fewer in numbers. We systematically reviewed the literature on the complications associated with lumbosacral interbody fusion. Only the PLIF, ALIF, or TLIF approaches and studies published within the last decade (2007–2017) were included. The exclusion criteria in this study were oblique lumbar interbody fusion, extreme lateral interbody fusion, more than one procedure per patient, and reported patient numbers less than 10. The outcome variables were indications, fusion rates, operation time, perioperative complications, and clinical outcome by means of Visual Analog Scale, Oswestry Disability Index, and Japanese Orthopaedic Association score. Five prospective, 17 retrospective, and two comparative studies that investigated the lumbosacral region were included. Mean fusion rates were 91,4%. ALIF showed a higher operation time, while PLIF resulted in greater blood loss. In all approaches, significant improvements in the clinical outcome were achieved, with ALIF showing slightly better results. Regarding complications, the ALIF technique showed the highest complication rates. Lumbosacral fusion surgery is a treatment to provide good results either through an approach for various indications as causes of lower back pain. For each surgical approach, advantages can be depicted. However, perioperative complications and risk factors are numerous and vary with ALIF, PLIF, and TLIF procedures, as well as with fusion rates.
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Affiliation(s)
- Maximilian Lenz
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaliye Mohamud
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jan Bredow
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Stavros Oikonomidis
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Max Joseph Scheyerer
- Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
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Karsy M, Chan AK, Mummaneni PV, Virk MS, Bydon M, Glassman SD, Foley KT, Potts EA, Shaffrey CI, Shaffrey ME, Coric D, Asher AL, Knightly JJ, Park P, Fu KM, Slotkin JR, Haid RW, Wang M, Bisson EF. Outcomes and Complications With Age in Spondylolisthesis: An Evaluation of the Elderly From the Quality Outcomes Database. Spine (Phila Pa 1976) 2020; 45:1000-1008. [PMID: 32097272 DOI: 10.1097/brs.0000000000003441] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective database analysis. OBJECTIVE To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3% to 20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients. METHODS The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 US academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016. RESULTS A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: less than 60 (n = 239), 60 to 70 (n = 209), 71 to 80 (n = 128), and more than 80 (n = 32) years. Older patients showed lower mean body mass index (P < 0.001) and higher rates of diabetes (P = 0.007), coronary artery disease (P = 0.0001), and osteoporosis (P = 0.005). A lower likelihood for home disposition was seen with higher age (89.1% in <60-year-old vs. 75% in >80-year-old patients; P = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EuroQol health survey [EQ-5D], Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (P < 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (P < 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs. CONCLUSION Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter US study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Michael Karsy
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Michael S Virk
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin T Foley
- Department of Neurological Surgery, University of Tennessee Health Science Center, Semmes Murphey Neurologic and Spine Institute, Memphis, TN
| | - Eric A Potts
- Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, IN
| | | | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Domagoj Coric
- Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery & Spine Associates, Charlotte, NC
| | - Anthony L Asher
- Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery & Spine Associates, Charlotte, NC
| | | | - Paul Park
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | | | - Michael Wang
- Department of Neurosurgery, University of Miami, Miami, FL
| | - Erica F Bisson
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
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Impact of the Number of Levels on Adverse Events and Length of Stay Following Posterior Lumbar Fusion Procedures. Clin Spine Surg 2019; 32:120-124. [PMID: 30407262 DOI: 10.1097/bsd.0000000000000739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective SUMMARY OF BACKGROUND DATA:: Little is known regarding the impact of the number of operative levels on the risk for adverse events following spinal procedures. OBJECTIVE The objective of this study was to test for associations between the number of operative levels and occurrence of adverse events following posterior lumbar fusion (PLF). METHODS Patients undergoing 1-, 2-, or 3-level PLFs were identified in the American College of Surgeons National Surgical Quality Improvement Program database. The number of operative levels was tested for association with occurrence of adverse events in the 30-days following the procedure using multivariate regression. Post hoc pairwise comparisons were made between 1- and 2-level and between 2- and 3-level procedures. Analyses were adjusted for differences in baseline characteristics. RESULTS In total, 8162 underwent 1-level, 3,527 underwent 2-level, and 718 underwent 3-level procedures. Patients undergoing 2-level procedures had a higher rate of anemia requiring blood transfusion than 1-level procedures (23.4% vs. 8.6%; adjusted relative risk [RR]=2.5; P<0.001). Furthermore, patient undergoing 3-level procedures had a higher rate of anemia requiring blood transfusion than 2-level procedures (29.9% vs. 23.4%; adjusted RR=1.3; P<0.001). In addition, patients undergoing 3-level procedures had a longer length of stay than 2-level procedures (4.6 vs. 3.9 d; P<0.001) and 2-level procedures had a longer length of stay than 1-level procedures (3.9 vs. 3.5 d; P<0.001). CONCLUSIONS Increasing the number of operative levels by one level has minimal impact on the rates of most short-term postoperative adverse events following PLF. This is true both for an increase from 1 to 2 levels and from 2 to 3 levels. While surgeons should consider that an increase in the number of operative levels may increase the risk for blood transfusion and will almost certainly prolong the hospital stay, they need not fear a major increase in the rates of postoperative adverse events.
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Bindal S, Bindal SK, Bindal M, Bindal AK. Noninstrumented Lumbar Fusion with Bone Morphogenetic Proteins for Spinal Stenosis with Spondylolisthesis in the Elderly. World Neurosurg 2019; 126:e1427-e1435. [PMID: 30904805 DOI: 10.1016/j.wneu.2019.02.251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study examined the use of noninstrumented posterolateral lumbar fusion with bone morphogenetic protein (BMP) and compared its effectiveness with that of instrumented fusion for the treatment of lumbar spinal stenosis (LSS) with spondylolisthesis in elderly patients. METHODS This study was a retrospective review of 93 patients treated in a single-surgeon neurosurgical private practice over a 15-year period. Fifty-nine patients over the age of 65 who underwent noninstrumented posterolateral fusion with rhBMP-2 (Infuse) for LSS with spondylolisthesis were compared with 34 patients who underwent instrumented fusion without rhBMP-2. Outcomes in terms of reoperation rate, pain improvement, Oswestry Disability Index (ODI) score, and number of extra follow-up visits due to persistent problems were characterized by the use of t tests and χ2 tests. RESULTS The reoperation rate in the noninstrumented rhBMP-2 fusion group was significantly lower than in the instrumented fusion group (17.6% vs. 3.4%, P = 0.048). The mean pain improvement was significantly higher in the noninstrumented rhBMP-2 group at 3 months (8.1 vs. 6.0, P < 0.001, 95% confidence interval [CI] 1.2 to 3.0) and at 1 year (7.25 vs. 5.6, P = 0.030, 95% CI 0.3 to 3.1). The ODI score improvement was significantly higher in the noninstrumented rhBMP-2 group (51 vs. 42.8, P < 0.001, 95% CI 4.7 to 11.6). The mean number of additional follow-up visits per patient was significantly lower in the noninstrumented rhBMP-2 group (0.068 vs. 1.23, P < 0.001, 95% CI 0.59 to 1.75). CONCLUSION Noninstrumented posterolateral lumbar fusion with rhBMP-2 in elderly patients with LSS and spondylolisthesis is a viable alternative to instrumented fusion based on clinical outcomes measured in this study.
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Levin JM, Tanenbaum JE, Steinmetz MP, Mroz TE, Overley SC. Posterolateral fusion (PLF) versus transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis: a systematic review and meta-analysis. Spine J 2018; 18:1088-1098. [PMID: 29452283 DOI: 10.1016/j.spinee.2018.01.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/22/2017] [Accepted: 01/29/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy. PURPOSE The present study aims to compare the clinical outcomes, fusion rates, blood loss, and operative times between open posterolateral lumbar fusion (PLF) alone and open transforaminal lumbar interbody fusion (TLIF) + posterolateral fusion for spondylolisthesis. STUDY DESIGN This is a systematic literature review and meta-analysis of English language studies for the treatment of spondylolisthesis with PLF versus PLF + TLIF. PATIENT SAMPLE Data were obtained from published randomized controlled trials (RCTs) and retrospective cohort studies. OUTCOME MEASURES Clinical outcomes included Oswestry Disability Index (ODI), back pain, leg pain, and health-related quality of life (HRQOL) scores. Fusion rate, operative time, blood loss, and infection rate were also assessed. METHODS A literature search of three electronic databases was performed to identify investigations performed comparing PLF alone with PLF + TLIF for treatment of low-grade lumbar spondylolisthesis. The summary effect size was assessed from pooling observational studies for each of the outcome variables, with odds ratios (ORs) used for fusion and infection rate, mean difference used for improvement in ODI and leg pain as well as operative time and blood loss, and standardized mean difference used for improvement in back pain and HRQOL outcomes. Studies were weighed based on the inverse of the variance and heterogeneity. Heterogeneity was assessed using the I2-an estimate of the error caused by between-study variation. Effect sizes from the meta-analysis were then compared with data from the RCTs to assess congruence in outcomes. RESULTS The initial literature search yielded 282 unique, English language studies. Seven were determined to meet our inclusion criteria and were included in our qualitative analysis. Five observational studies were included in our quantitative meta-analysis. The pooled fusion success rates were 84.7% (100/118) in the PLF group and 94.3% (116/123) in the TLIF group. Compared with TLIF patients, PLF patients had significantly lower odds of achieving solid arthrodesis (OR 0.33, 95% confidence interval [CI] 0.13-0.82, p=.02; I2=0%). With regard to improvement in back pain, the point estimate for the effect size was -0.27 (95% CI -0.43 to -0.10, p=.002; I2=0%), in favor of the TLIF group. For ODI, the pooled estimate for the effect size was -3.73 (95% CI -7.09 to -0.38, p=.03; I2=35%), significantly in favor of the TLIF group. Operative times were significantly shorter in the PLF group, with a summary effect size of -25.55 (95% CI -43.64 to -7.45, p<.01; I2=54%). No significant difference was observed in leg pain, HRQOL improvement, blood loss, or infection rate. Our meta-analysis results were consistent with RCTs, in favor of TLIF for achieving radiographic fusion and greater improvement in ODI and back pain. CONCLUSIONS Our results demonstrate that for patients undergoing fusion for spondylolisthesis, TLIF is superior to PLF with regard to achieving radiographic fusion. However, current data only provide weak support, if any, favoring TLIF over PLF for clinical improvement in disability and back pain.
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Affiliation(s)
- Jay M Levin
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA.
| | - Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Population and Quantitative Health Science, Case Western Reserve University, 2109 Adelbert Rd, Cleveland, OH 44106, USA
| | - Michael P Steinmetz
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA
| | - Samuel C Overley
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-40, Cleveland, OH 44195, USA
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Day M, Westermann R, Duchman K, Gao Y, Pugely A, Bollier M, Wolf B. Comparison of Short-term Complications After Rotator Cuff Repair: Open Versus Arthroscopic. Arthroscopy 2018; 34:1130-1136. [PMID: 29305290 DOI: 10.1016/j.arthro.2017.10.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/11/2017] [Accepted: 10/13/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To define and compare the incidence and risk factors for short-term complications after arthroscopic and open rotator cuff repair (RTCR), and to identify independent risk factors for complications after RTCR. METHODS All patients who underwent open or arthroscopic RTCR from 2005 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Short-term complications were categorized as surgical, medical, mortality, and unplanned 30-day readmission. Univariate analysis allowed the comparison of patient demographics and comorbidities. Propensity score matching was used to control for demographic differences between arthroscopic and open RTCR patient groups. Independent risk factors for complication were identified using multivariate logistic regression. RESULTS Overall, 11,314 RTCRs were identified (24% open, 76% arthroscopic). The mean operative time for open RTCR was 78 minutes compared with 91 minutes for arthroscopic repairs (P < .001). The overall complication rate was 1.3%, with the highest complication unplanned return to the operating room (41 patients, 0.36%). The 30-day readmission was 1.16% (76/6,560 patients) and the mortality rate was 0.03% (3 patients). Total 30-day complications in the propensity-score-matched patient group were higher after open versus arthroscopic repair (1.79% vs 1.17%; P = .006). The overall infection rate after RTCR was 0.56%, with deep wound infection higher in the open repair patient group (P = .003). Multivariate analysis identified age >65 years (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2-2.3), operative time >90 minutes (OR 1.5; CI 1.1-2.1), and open RTCR (OR 1.6; CI 1.1-2.3) as independent risk factors for complications. CONCLUSIONS Short-term complications after RTCR are rare. Total complications are higher after open RTCR in propensity-matched patient groups and in multivariate analysis. Risk factors for complications include patient age >65, operative time >90 minutes, and open repair. Open RTCR is associated with an increased risk of surgical infections. LEVEL OF EVIDENCE Level III, retrospective comparative trial.
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Affiliation(s)
- Molly Day
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A..
| | - Robert Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Kyle Duchman
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Yubo Gao
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Andrew Pugely
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Matthew Bollier
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Brian Wolf
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
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