Search

Symptomatic lumbar spinal stenosis is routinely treated with spinal decompression surgery, with an increasing trend towards minimally invasive techniques. Endoscopic decompression has emerged as a technique which minimizes approach-related morbidity while achieving similar clinical outcomes to conventional open or microscopic approaches. To assess the safety and efficacy of endoscopic versus microscopic decompression for treatment of lumbar spinal stenosis. Systematic review and meta-analysis. A systematic review on randomized and nonrandomized studies comparing endoscopic versus microscopic decompression was conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Treatment effects were computed using pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk-of-bias and ROBINS-I tools for randomized and nonrandomized trials respectively. Quality of the overall body of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. A total of 19 primary references comprising 1,997 patients and 2,132 spinal levels were included. Endoscopic decompression was associated with significantly reduced intraoperative blood-loss (weighted mean differences [WMD]=−33.29 mL, 95% CI:−51.80 to −14.78, p=.0032), shorter duration of hospital stay (WMD=−1.79 days, 95% CI: -2.63 to 0.95, p=.001), rates of incidental durotomy (RR = 0.63, 95% CI: 0.43 to 0.91, p=.0184) and surgical site infections (RR=0.23, 95% CI: 0.10 to−0.51, p=.001), and a nonsignificant trend towards less back pain, leg pain, and better functional outcomes compared to its microscopic counterpart up to 2-year follow up. Endoscopic and microscopic decompression are safe and effective techniques for treatment of symptomatic lumbar spinal stenosis. Prospective studies of larger power considering medium to long-term outcomes and rates of iatrogenic instability are warranted to compare potential alignment changes and destabilization from either techniques. [ABSTRACT FROM AUTHOR]

• This was a large population-based study of working-aged Northern Finns. • Multisite pain was clearly the factor most strongly associated with sciatica. • The effect sizes of the remaining factors were clearly smaller. Sciatica is defined as pain radiating from the low back to the leg, usually below the knee. It is a disabling condition that causes a major burden to health care and society. Previous evidence of the multifactorial etiology of sciatica comes mostly from cross-sectional studies. Larger, longitudinal studies with a multidimensional set of variables are needed. To examine how socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain are associated with sciatica. A longitudinal study of the Northern Finland Birth Cohort 1966. In total 6,683 working-aged members of the Northern Finland Birth Cohort 1966. Self-reported sciatic pain status over a 15-year study period. We conducted a 15-year longitudinal study from the age of 31 to 46. We used multivariable generalized estimation equations analysis to examine how socioeconomic characteristics (low education, unemployment, and living alone), lifestyle characteristics (overweight, obesity, current smoking, and physical inactivity), psychological symptoms (depression, anxiety), multimorbidity, and multisite pain were associated with sciatica. At the age of 31, 21.1% of the study population reported sciatic pain and at the age of 46, 36.7%. Multisite pain was clearly the strongest factor associated with sciatica (odds ratio [OR] 2.61, 95% confidence interval [CI] 2.34‒2.92). In descending order of effect size, older age, low education, psychological symptoms, multimorbidity, overweight, obesity, physical inactivity and current smoking were positively associated with sciatica. Their ORs varied between 1.17 and 2.18. Living alone was negatively associated with sciatica (OR 0.81, 95% CI 0.72‒0.90). Multisite pain had the strongest association with sciatica. The effect sizes of the other factors were clearly smaller. To our knowledge this is the first study to evaluate the association of multisite pain with sciatica. This finding may have considerable implications for clinical work treating patients with sciatica. [ABSTRACT FROM AUTHOR]

• Patients with L5-S1 FS showed poorer clinical outcomes after L4-5 PLIF. • These patients had higher back pain and ODI scores at final follow-up. • Mild-to-moderate FS at L5-S1 worsens sagittal balance. • L5-S1 FS group had more severe central and foraminal stenosis. Patients scheduled for L4−5 PLIF often have FS at L5-S1. However, data on the clinical and radiographic outcomes of cases with mild-to-moderate L5−S1 FS are lacking, which may affect clinical outcomes or require additional surgery after L4−5 fusion. To evaluate the clinical and radiographic outcomes of L4−5 PLIF in patients with and without mild-to-moderate L5−S1 FS, with a primary focus on the association between L5−S1 FS and postoperative clinical outcomes including back pain, leg pain, and scores on the oswestry disability index (ODI) and EuroQol 5-dimension (EQ-5D). Retrospective comparative study. A retrospective review of patients who underwent L4−5 PLIF from 2014 to 2018. The patients were divided according to the presence of mild-to-moderate FS at L5−S1. Clinical assessment included the pain visual analog scale (VAS), ODI, and EQ-5D score. Radiographic assessments included spinopelvic parameters and grades for central and foraminal stenosis. Clinical outcomes were assessed using validated outcome measures at preoperative, 6-month, 12-month, and 36-month follow-up visits. Radiographic evaluations were performed using preoperative and postoperative radiographs. Foraminal stenosis was assessed qualitatively using MRI with a grading system from none to severe and quantitatively by measuring changes in the foraminal area on CT. Among 186 patients, 55 were categorized as the FS group and 131 as the non-FS group. The FS group was older (p=0.039) and had more severe central stenosis at L5−S1 (p=0.007) as well as more severe FS at both L4−5 and L5−S1 (both p<0.001). Preoperative disc height (p<0.001), C7-S1 sagittal vertical axis (p=0.003), lumbar lordosis (p=0.005), and pelvic incidence–lumbar lordosis mismatch (p=0.026) were more aggravated in the FS group. The FS group showed inferior clinical outcomes at the final follow-up in terms of back pain (p=.010) and ODI score (p=.003). The presence of mild-to-moderate FS at L5–S1 was associated with more aggravated sagittal balance in terms of smaller preoperative disc height, larger sagittal vertical axis, smaller lumbar lordosis, and larger pelvic incidence–lumbar lordosis mismatch. Patients with L5−S1 FS also had poorer clinical outcomes including back pain and ODI score after L4−5 PLIF. Patients with L5−S1 FS need to be carefully examined before L4−5 fusion considering their adverse outcomes due to underlying degenerative changes. [ABSTRACT FROM AUTHOR]

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS. This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS. Randomized, single-blinded, multi-center, parallel-group clinical trial. One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period. The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months. Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63). At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group. Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up. [ABSTRACT FROM AUTHOR]

With an increasing number of web-based calculators designed to provide the probabilities of an individual achieving improvement after lumbar spine surgery, there is a need to determine the accuracy of these models. To perform an internal and external validation study of the reduced Quality Outcomes Database web-based Calculator (QOD-Calc). Observational longitudinal cohort. Patients enrolled study-wide in Quality Outcomes Database (QOD) and patients enrolled in DaneSpine at a single institution who had elective lumbar spine surgery with baseline data to complete QOD-Calc and 12-month postoperative data. Oswestry Disability Index (ODI), Numeric Rating Scales (NRS) for back and leg pain, EuroQOL-5D (EQ-5D). Baseline data elements were entered into QOD-Calc to determine the probability for each patient having Any Improvement and 30% Improvement in NRS leg pain, back pain, EQ-5D and ODI. These probabilities were compared with the actual 12-month postop data for each of the QOD and DaneSpine cases. Receiver-operating characteristics analyses were performed and calibration plots created to assess model performance. 24,755 QOD cases and 8,105 DaneSpine lumbar cases were included in the analysis. QOD-Calc had acceptable to outstanding ability (AUC: 0.694–0.874) to predict Any Improvement in the QOD cohort and moderate to acceptable ability (AUC: 0.658–0.747) to predict 30% Improvement. QOD-Calc had acceptable to exceptional ability (AUC: 0.669–0.734) to predict Any improvement and moderate to exceptional ability (AUC: 0.619–0.862) to predict 30% Improvement in the DaneSpine cohort. AUCs for the DaneSpine cohort was consistently lower that the AUCs for the QOD validation cohort. QOD-Calc performs well in predicting outcomes in a patient population that is similar to the patients that was used to develop it. Although still acceptable, model performance was slightly worse in a distinct population, despite the fact that the sample was more homogenous. Model performance may also be attributed to the low discrimination threshold, with close to 90% of cases reporting Any Improvement in outcome. Prediction models may need to be developed that are highly specific to the characteristics of the population. [ABSTRACT FROM AUTHOR]

The proportion of patients who undergo lumbar microdiscectomy due to lumbar radiculopathy who are also overweight or obese is high. However, whether high body mass index (BMI) affects clinical outcomes is not well-studied. To investigate the difference in the clinical course between normal weight, overweight, and obese patients with radiculopathy who underwent lumbar microdiscectomy followed by physical therapy and to evaluate whether high BMI is associated with poor recovery. A prospective cohort study with a 12-month follow-up was conducted in a multidisciplinary clinic. We included 583 patients (median [IQR] age: 45 [35–52] years; 41% female) with clinical signs and symptoms of lumbar radiculopathy, consistent with magnetic resonance imaging findings, who underwent microdiscectomy followed by postoperative physical therapy. Outcomes were leg pain and back pain intensity measured with a visual analogue scale, disability measured with the Roland Morris Disability Questionnaire at 3 and 12-month follow-ups, and complications. Patients were classified as being normal weight (46.9%), overweight (38.4%), or obese (14.7%). A linear mixed-effects model was used to assess the difference in the clinical course of pain and disability between the three BMI categories. The association between BMI and outcomes was evaluated using univariable and multivariable logistic regression analyses. All three patient groups experienced a significant improvement in leg pain, back pain, and disability over 3 and 12-month follow-up. Patients who were overweight, obese, or normal weight experienced comparable leg pain (p=.14) and disability (p=.06) over the clinical course (p=.14); however, obese patients experienced higher back pain (MD=−6.81 [95%CI: −13.50 to −0.14]; p=.03). The difference in back pain scores was not clinically relevant. In the first year following lumbar microdiscectomy, patients demonstrated clinical improvements and complications that were unrelated to their preoperative BMI. [ABSTRACT FROM AUTHOR]

Unplanned readmissions following lumbar spine surgery have immense clinical and financial implications. However, little is known regarding the impact of unplanned readmissions on patient-reported outcomes (PROs) following lumbar spine surgery. To evaluate the impact of unplanned readmissions, including specific readmission reasons, on patient reported outcomes 12 months after lumbar spine surgery. A retrospective cohort study of prospectively collected data was conducted using patients included in the lumbar module of the Quality and Outcomes Database (QOD), a national, multicenter spine registry. A total of 33,447 patients who underwent elective lumbar spine surgery for degenerative diseases were included. Mean age was 59.8 (SD=14.04), 53.6% were male, 89.5% were white, 45.9% were employed, and 47.5% had private insurance. Unplanned 90-day readmissions and 12-month patient-reported outcomes (PROs) including numeric rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI) scores, EuroQol-5 Dimension (EQ-5D) scores, and North American Spine Society (NASS) patient-satisfaction scores. The lumbar module of the QOD was queried for adults undergoing elective lumbar spine surgery for degenerative disease. Unplanned 90-day readmissions were classified into 4 groups: medical, surgical, pain-only, and no readmissions. Medical and surgical readmissions were further categorized into primary reason for readmission. 12-month PROs assessing patient back and leg pain (NRS), disability (ODI), quality of life (EQ-5D), and patient satisfaction were collected. Multivariable models predicting 12-month PROs were built controlling for covariates. A total of 31,430 patients (94%) had no unplanned readmission while 2,017 patients (6%) had an unplanned readmission within 90 days following lumbar surgery. Patients with readmissions had significantly worse 12-month PROs compared with those with no unplanned readmissions in covariate-adjusted models. Using Wald-df as a measure of predictor importance, surgical readmissions were associated with the worst 12-month outcomes, followed by pain-only, then medical readmissions. In separate covariate adjusted models, we found that readmissions for pain, SSI/wound dehiscence, and revisions were among the most important predictors of worse outcomes at 12-months. Unplanned 90-day readmissions were associated with worse pain, disability, quality of life, and greater dissatisfaction at 12-months, with surgical readmissions having the greatest impact, followed by pain-only readmissions, then medical readmissions. Readmissions for pain, SSI/wound dehiscence, and revisions were the most important predictors of worse outcomes. These results may help providers better understand the factors that impact outcomes following lumbar spine surgery and promote improved patient counseling and perioperative management. [ABSTRACT FROM AUTHOR]

Little information is available about the minimal clinically important differences (MCIDs) for objective physical measurements in people with lumbar spinal stenosis (LSS). To use disorder-specific anchor and, multiple anchor-, and distribution-based approaches to determine the MCIDs for walking capacity and physical activity in patients with LSS receiving nonsurgical treatment. Secondary analysis of a randomized controlled trial. Sixty-nine patients with neurogenic claudication caused by LSS receiving outpatient physical therapy. Zurich claudication questionnaire (ZCQ), self-paced walking test (SPWT), and number of daily steps measured by pedometry. All patients completed the ZCQ, SPWT, and pedometry at the baseline and after 6 weeks. For the anchor-based approach, ZCQ symptom severity, physical function, and satisfaction subscales were used as the external anchors. Using the receiver-operating characteristic (ROC) curve, the MCIDs were determined based on the optimal cutoff points for changes in the SPWT or daily steps. For the distribution-based approach, the MCIDs were estimated from the standard deviations (SDs) of the baseline scores of the SPWT and daily steps. In the anchor-based approach, only the ZCQ satisfaction subscale for the SPWT (0.73), and ZCQ symptom severity subscale for daily steps (0.71) exceeded the area under the ROC curve value of 0.7, which is considered acceptable. When using these subscales as anchors, the ROC curves and optimal cutoff points indicated MCIDs of 151 m for the SPWT and 1,149 steps for daily steps. The distribution-based approach estimated the MCIDs as 280 m for the SPWT and 1,274 steps for daily steps, and had a moderate effect size (0.5 SD). The anchor-based approach had limited external responsiveness when the ZCQ was used as the anchor. However, this information may be helpful for interpreting walking capacity and physical activity in patients with LSS receiving nonsurgical treatment and for estimating power and sample size when planning new trials. [ABSTRACT FROM AUTHOR]

Facet joint osteoarthritis (FJOA) is associated with lumbar disc degeneration and has a significant role in the development of lumbar spinal stenosis (LSS). The relationship between various radiographic parameters and the grade of FJOA is not well understood. To explore radiographical parameters associated with FJOA in LSS without lumbar dynamic instability. Retrospective study analysis. A total of 122 patients diagnosed with LSS who visited our hospital between January 2015 and July 2022. We evaluated radiographic parameters of patients at L4-5 including lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), grades of FJOA, facet joint orientation (FO), facet joint tropism (FT), intervertebral height index (IHI) and the relative cross-sectional area (RCSA) of paraspinal muscles. Patients diagnosed with LSS between January 2015 and July 2022 were enrolled. Demographic characteristics and radiographic parameters were collected. Spinopelvic parameters were measured through the preoperative lateral image of the whole spine, including LL, PI, pelvic tilt, and sacral slope. Lumbar computed tomography scan and magnetic resonance imaging were collected to measure the FO, FT, IHI, and the RCSA of paraspinal muscles respectively. Patients were divided into three groups according to the severity of FJOA graded by the Weishaupt classification: grade 0 and grade 1 were group A, grade 2 were group B, and grade 3 were group C. All variables were compared among the three groups, while the relationship between parameters and grades of FJOA were also analyzed. A total of 122 patients were included. PI was significantly greater in group C compared to group A (p = 0.025) and group B (p=0.022). FT was significantly greater in group C compared to group A (p<.001) and group B (p<.001). The RCSA of multifidus in group A were significantly greater than that in group B (p=0.02) and C (p=0.002). Additionally, FO in group C were significantly lower than group A (p<.001) and group B (p=0.028). The IHI in group C was significantly lower than group A (p=0.017). The correlation analysis indicated that grades of FJOA was positively related to Age, BMI (body mass index), PI, LL and FT, while negatively related to IHI, FO, RCSA of multifidus and RCSA of psoas major. Furthermore, the logistics regression showed that FT, PI, and IHI were important influence factors for FJOA. The current study confirmed that FT, PI and IHI were significantly associated with grades of FJOA at L4-5. Additionally, longitudinal studies are needed to understand the causal relationship between these parameters and FJOA. [ABSTRACT FROM AUTHOR]

Prior studies suggest that patient expectations impact postoperative patient-reported outcomes (PROMs). However, no consensus exists on an appropriate expectations tool. To examine the impact of patient expectations using a modified version of the Oswestry Disability Index (ODI) on clinical outcomes and patient satisfaction 1 year after lumbar fusion for degenerative pathologies. Prospective longitudinal cohort. Adults undergoing 1 to 2 level lumbar fusion were identified from four tertiaty spine centers. ODI, EuroQol-5D, Numeric rating scales for back and leg pain. Preoperatively, patients completed the ODI, as well as a modified ODI reflecting their expected improvement across the 10 ODI items. For example, item 1 in the ODI asks about Pain Intensity at the moment whereas the Expectations ODI asks "One year after surgery, I expect to have..." The difference between this modified ODI score and the baseline ODI score (Baseine ODI minus Expectations ODI) was defined as the Patient Expectation Score. Patients were stratified into tertiles based on their Expectations score into High (HE), Moderate (ME), and Low (LE) Expectations and compared. There were 30 patients in the HE, 35 in the ME, and 26 in the LE Group, with similar demographics and surgical parameters. Patients in the HE group had worse ODI scores preoperatively (54.96 vs 41.42, p<.001) and were expecting a greater improvement in ODI (43.8 vs 13.5, p<.001). There were fewer patients in the HE group (13, 43%) who reported that they were satisfied with the results compared to either the ME (20, 71%) or LE group (22, 85%, p=.041) despite having similar ODI scores and change in ODI scores 1 year postoperatively. An expectations tool, linked to a disease-specific measure may provide the clinician with a practical method of assessing a patient's expectation of results after treatment and aid in the shared decision-making during the preoperative surgical process. [ABSTRACT FROM AUTHOR]

The use of static cages for lumbar interbody fusion (LIF) can cause complications such as end plate violation, graft subsidence, and nerve injury. Therefore, expandable cages that allow for in-situ expansion have been developed to overcome these problems. However, it remains uncertain whether expandable cages have better surgical outcomes than static cages do. We aimed to determine the effectiveness of expandable cages by analyzing studies that compared the surgical outcomes between the use of expandable cages and static cages. A systematic review and meta-analysis. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to conduct this meta-analysis and systematic review. The primary outcomes of this study were anterior disc height, posterior disc height, segmental lordosis (SL), lumbar lordosis (LL), subsidence rate, numeric rating scale (NRS) scores for back and leg pain, and Oswestry Disability Index (ODI). Thirteen studies with 1,700 patients were included in the meta-analysis. Compared with static cages for LIFs, expandable cages significantly increased the anterior disc height (standardized mean difference 0.478, 95% confidence interval [CI] 0.088–0.867, p=.0162) and segmental lordosis (sMD 0.307, 95% CI 0.159–0.454, p<.0001). There were no significant differences in the posterior disc height, lumbar lordosis, subsidence rate, back pain, leg pain, or ODI between the two groups. Expandable cages show no clear clinical benefit over static cages. [ABSTRACT FROM AUTHOR]

Lumbar spinal stenosis (LSS) has been reported to induce changes in paraspinal muscle morphology, but objective physical function and degenerative spine conditions are rarely assessed. To identify factors associated with paraspinal muscle morphology using objective physical and degenerative spine assessments in patients with LSS. Cross-sectional design. Seventy patients with neurogenic claudication caused by LSS, receiving outpatient physical therapy. Cross-sectional area (CSA) and functional CSA (FCSA) of the multifidus, erector spinae, and psoas muscles, the severity of stenosis, disc degeneration, and endplate abnormalities were evaluated by magnetic resonance imaging, as well as sagittal spinopelvic alignment by X-ray. Objective physical assessments included pedometry and claudication distance. Patient-reported outcomes included the numerical rating scale of low back pain, leg pain, and leg numbness, and the Zurich Claudication Questionnaire. To assess the impact of LSS on paraspinal muscles, FCSA and FCSA/CSA were compared between the dominant and nondominant sides based on the patients' neurogenic symptoms, and multivariable regression analyses adjusted for age, sex, height, and weight were performed; p<.05 was considered significant. Seventy patients were analyzed. At one level below the maximum stenotic level, erector spinae FCSA on the dominant side was significantly lower than that on the nondominant side. In the multivariable regression analyses, at one level below the symptomatic level, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, such as decreased lumbar lordosis and increased pelvic tilt, were negatively associated with multifidus FCSA and FCSA/CSA ratio. A significant association was observed between dural sac CSA and erector spinae FCSA. Throughout L1/2 to L5/S, disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment were negatively associated with multifidus and erector spinae FCSA or FCSA/CSA. Lumbar paraspinal muscle asymmetry caused by LSS was observed only in erector spinae. Disc degeneration, endplate abnormalities, and lumbar spinopelvic alignment, rather than spinal stenosis and LSS symptoms, were more associated with paraspinal muscle atrophy or fat infiltration. [ABSTRACT FROM AUTHOR]

• More preoperative leg pain and less comorbidity associated with improved outcome. • Baseline variables did not modify the treatment effect. • Instability criteria cannot be recommended as selection criteria for fusion surgery. Patients with spinal stenosis and degenerative spondylolisthesis are treated surgically with decompression alone or decompression with fusion. However, there is debate regarding which subgroups of patients may benefit from additional fusion. To investigate possible treatment effect modifiers and prognostic variables among patients operated for spinal stenosis and degenerative spondylolisthesis. A secondary exploratory study using data from the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis (NORDSTEN-DS) trial. Patients were randomized to decompression alone or decompression with instrumented fusion. The sample in this study consists of 267 patients from a randomized multicenter trial involving 16 hospitals in Norway. Patients were enrolled from February 12, 2014, to December 18, 2017. The study did not include patients with degenerative scoliosis, severe foraminal stenosis, multilevel spondylolisthesis, or previous surgery. The primary outcome was an improvement of ≥ 30% on the Oswestry Disability Index score (ODI) from baseline to 2-year follow-up. When investigating possible variables that could modify the treatment effect, we analyzed the treatment arms separately. When testing for prognostic factors we analyzed the whole cohort (both treatment groups). We used univariate and multiple regression analyses. The selection of variables was done a priori, according to the published trial protocol. Of the 267 patients included in the trial (183 female [67%]; mean [SD] age, 66 [7.6] years), complete baseline data for the variables required for the present analysis were available for 205 of the 267 individuals. We did not find any clinical or radiological variables at baseline that modified the treatment effect. Thus, none of the commonly used criteria for selecting patients for fusion surgery influenced the chosen primary outcome in the two treatment arms. For the whole cohort, less comorbidity (American Society of Anesthesiologists Classification [ASA], OR = 4.35; 95% confidence interval (CI [1.16–16.67]) and more preoperative leg pain (OR = 1.23; CI [1.02–1.50]) were significantly associated with an improved primary outcome. In this study on patients with degenerative spondylolisthesis, neither previously defined instability criteria nor other pre-specified baseline variables were associated with better clinical outcome if fusion surgery was performed. None of the analyzed variables can be applied to guide the decision for fusion surgery in patients with degenerative spondylolisthesis. For both treatment groups, less comorbidity and more leg pain were associated with improved outcome 2 years after surgery. NORDSTEN-DS ClinicalTrials.gov, NCT02051374. [ABSTRACT FROM AUTHOR]

Degenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS. To identify the effect of postoperative sagittal spinal alignment on functional outcome after DLS surgery. Retrospective cohort study. Two-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database. Baseline and 1-year postoperative leg and back pain on the 10-point Numeric Rating Scale and baseline and 1-year postoperative disability on the Oswestry Disability Index (ODI). All enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and 1-year postoperatively including sagittal vertical axis (SVA), pelvic incidence and lumbar lordosis (LL). Both univariate and multiple linear regression was used to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors. Two-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse pelvic incidence-LL mismatch was correlated with more severe disability [ODI, 0.134, p<.05), worse leg pain (0.143, p<.05) and worse back pain (0.189, p<.001) 1-year postoperatively. These associations were maintained after adjusting for age, BMI, gender, and preoperative presence of depression (ODI, R2 0.179, β, 0.25, 95% CI 0.08, 0.42, p=.004; back pain R2 0.152 (β, 0.05, 95% CI 0.022, 0.07, p<.001; leg pain score R2 0.059, β, 0.04, 95% CI 0.008, 0.07, p=.014). Likewise, reduction of LL was associated with worse disability (ODI, R2 0.168, β, 0.04, 95% CI -0.39, -0.02, p=.027) and worse back pain (R2 0.135, β, -0.04, 95% CI -0.06, -0.01, p=.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R2 0.236, β, 0.12, 95% CI 0.05, 0.20, p=.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R2 0.136, β, 0.01, 95% CI.001, 0.02, p=.029) and worse NRS leg pain (R2 0.065, β, 0.02, 95% CI 0.002, 0.02, p=.018) scores regardless of surgery type. Preoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment. [ABSTRACT FROM AUTHOR]

Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches. To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery. Prospective, multicenter, international, observational cohort study. Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion. Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t -tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison. Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390). Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach. • Real world data from a large global sample of patients with spondylolisthesis. • Clinically significant improvement up to 12-months after minimally invasive fusion. • No clinically relevant differences between anterolateral and posterior approaches. [ABSTRACT FROM AUTHOR]

Preoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis. The primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment. Patients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry. Patients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included. The North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year. Expectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression. Three hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures. Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001]. Postoperative expectations fulfillment did not differ between procedures. Preoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures. [ABSTRACT FROM AUTHOR]

Degenerative grade 1 spondylolisthesis is associated with lumbar instability, typically addressed with decompression and fusion to prevent iatrogenic instability. The SLIP trial indicated that decompression-only patients benefit significantly from early reoperation for instability. Yet, it's unclear how these revision patients' outcomes compare to those undergoing primary fusion. To evaluate whether outcomes were inferior among patients receiving revision transforaminal lumbar interbody fusion (TLIF) after prior decompression in the setting of degenerative, grade 1 spondylolisthesis when compared to those undergoing primary TLIF for grade 1 spondylolisthesis. Retrospective cohort study. Patients with grade 1 spondylolisthesis at L4-L5 or L5-S1 who underwent TLIF between 2018-2023 and had complete 1Y clinical follow-up and 6-month (6M) patient reported outcomes (PROs) were included. PROs (ODI, PROMIS, SF-12, VAS Pain) and Clinical (readmission and reoperation at 6-week [6W], 6M, and 1Y). No predictors for missing data were identified. Comparisons were made between primary fusion patients and those with prior decompression now undergoing revision TLIF. Bias was minimized via 2:1 propensity score matching (PSM) for age, comorbidities (CCI), slip percentage, slip translation, angular change, anterior and posterior disc height (ADH and PDH respectively), facet diastasis and cysts, and facet orientation—termed spondylolisthesis characteristics. Unmatched PROs and clinical outcomes were analyzed with a mixed-effects (ME) model and Chi-Squared test, while matched PROs and clinical outcomes employed an ME model and conditional logistic regression. A total of 285 patients (55.4% female, mean age 60.80 ± 0.73, CCI of 2.10 ± 0.09, and 35.1% current/former smokers) were included. Spondylolisthesis slip was 13.11% ± 0.99% with mean translation in flexion/extension of 1.60 ± 0.19 mm. Compared to revision patients (N=42, 14.7%), primary fusion patients (N=243, 85.3%) were younger (59.70 ± 0.77 vs 67.20 ± 1.76) and had a lower prevalence of active smoking (2.48% vs 11.90%), but showed no differences in slip percentage (p=0.480), translation in flexion/extension (p=0.778), ADH(p=0.578), PDH(p=0.991), facet diastasis (p=0.132), facet cysts (p=0.550), or angular change across L3-S1. Preoperatively, PROs were comparable across all domains. At one-year postop, no differences were observed in back pain (p=0.430), leg pain (p=0.346), SF-12 PCS(p=0.976), MCS(p=0.737), PROMIS Score (p=0.063), or ODI(p=0.362). The PSM cohort, matched for age, CCI, and spondylolisthesis characteristics, showed standardized differences of less than 0.10 for all demographics, baseline PROs, and spondylolisthesis characteristics, aside angular change at L5-S1 (3.05 vs 7.08, p=0.062). At one-year postop, there were no differences in back pain (2.62 vs 2.10, p=0.414), leg pain (2.15 vs 1.48, p=0.270), SF-12 PCS (43.02 vs 43.38, p=0.888), SF-12 MCS (51.31 vs 52.80, p=0.553), PROMIS Score (45.69 vs 44.81, p=0.630), and ODI (18.66 vs 15.26, p=0.375). Finally, no significant differences were found in early (6W) or long-term (6M to 1Y) complications, with 98.1% primary and 90.5% revision patients complication-free at 6W, and 93.6% vs 100.0%, respectively, from 6M to 1Y. Following decompression alone for grade 1 spondylolisthesis, patients having revision TLIF after decompression exhibit patient-reported and clinical outcomes similar to those undergoing primary TLIF. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Evidence from recent RCTs and meta-analyses concluding that decompression with fusion is not superior to decompression alone should guide clinical practice. In contrast, a practice shift to decompression without fusion is not reported A possible reason is the lack of long-term evidence. To investigate whether decompression alone is noninferior to decompression with instrumented fusion 5 years after primary surgery. Investigator-initiated, open-label, randomized, controlled, multicentre noninferiority trial. A total of 267 patients aged 18 to 80 years with symptomatic lumbar spinal stenosis verified by magnetic resonance imaging (MRI) and ≥3 mm single-level spondylolisthesis at the stenotic level. The primary outcome was a reduction of 30% or more on the Oswestry Disability Index (ODI) from baseline to 5 years after surgery. Secondary outcomes included the mean scores on the ODI, the Zürich Claudication Questionnaire, the Numeric Rating Scale for leg and back pain, the EQ5D-3L, and the occurrence of a subsequent lumbar operation during 5 years. All analyses were performed based on a modified intention-to-treat (mITT) population. The null hypothesis was that the percentage of patients who met the primary outcome should be 15 percentage points lower in the decompression group than in the fusion group. To declare noninferiority for decompression-alone, the null hypothesis had to be rejected in both the mITT population (analyzed with multiple imputation of missing data) and in the per-protocol population (all who did not undergo reoperation during the follow-up period and had available data on the primary outcome). From February 12, 2014, to December 18, 2017, a total of 267 patients from 16 public surgical departments were randomized to decompression alone (n=134) and decompression with fusion (n=133), the baseline mean age was 66.2 years (SD 7.6), 68.5% were women, and 230 (88%) responded to the 5-year questionnaires. In the mITT population, 84/133 (63.2%) in the decompression group and 81/129 (62.8%) in the fusion group met the primary outcome (difference 0.4 percentage points, 95% CI, -11.9 to 11.2). Respectively proportions in the PPP analysis were 65/100 (65.0%) and 59/89 (66.3%), (difference -1.3 percentage points, 95% CI, -14.5 to 12.6). Both 95% CIs were above predefined margin of non-inferiority. The mean change in ODI from surgery to 5 years was −17.8 in both groups (mean difference 0.02, 95% CI -3.8 to 3.9). No differences were found in secondary outcomes. The reoperation rates from baseline to 5 years were 16.3% in the decompression group and 18.4% in the fusion group. In the NORDSTEN-DS trial of patients with degenerative spondylolisthesis, decompression alone remains noninferior to decompression with instrumented fusion 5 years after primary surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Currently, percutaneous endoscopic transforaminal lumbar discectomy (PTLD) has become increasingly popular in disc herniation. According to the variety of lumbar anatomy in each level, surgical and anesthesia techniques, safety and clinical outcomes are still controversial. Moreover, medical institutes in each area have different availability of equipment, for instance, neuro monitoring. Furthermore, some patients did not prefer to undergo local anesthesia for patient monitoring. Therefore, the purpose of this study was to evaluate the clinical and surgical outcomes of patients who were diagnosed L4-5 disc herniation treated with PTLD under local vs general anesthesia in 2 years by the same surgical team, who experienced more than 50 cases, using the same size of endoscope in all cases. To evaluate the clinical and surgical outcomes of patients who were diagnosed L4-5 disc herniation treated with PELD via transforaminal approach under local vs general anesthesia in two years. Retrospective study. A total of 73 consecutive patients who were diagnosed L4-5 disc herniation treated with PTLD in Thabo Crown Prince Hospital from January 2019 to November 2020. Patients were divided into LA group (n = 40) and general GA (n = 33) depending on the anesthesiologist and patients' preference. The clinical outcomes were evaluated by VAS for leg pain and back pain, ODI scores and the modified Macnab criteria at 1 day, 6 months, 1 year and 2 years postoperative We retrospectively analyzed 73 consecutive patients who were diagnosed L4-5 disc herniation treated with PTLD in Thabo Crown Prince Hospital from January 2019 to November 2020. Patients were divided into LA group (n = 40) and general GA (n = 33) depending on the anesthesiologist and patients' preference. The demographic characteristics and surgical results of the two groups were compared. The clinical outcomes were evaluated by VAS for leg pain and back pain, ODI scores and the modified Macnab criteria at 1 day, 6 months, 1 year and 2 years postoperative Seventy-three patients were enrolled. The majority of gender in LA and GA groups were male and female (p<0.05). The majority of technique in LA and GA groups was Inside-out (p<0.05). No significant differences in mean ages while mean operation time, intraoperative blood loss and length of stay were significantly lower in LA group (p<0.05). The postoperative VAS leg pain and back pain and ODI scores of two groups were significantly lower than those before surgery (p<0.05). For VAS leg pain, in LA group was significantly lower than GA group in 1 day postoperative (p<0.05). No significant differences between both groups in 6 months, 1 year and 2 years postoperative (p>0.05). For VAS back pain, no significant differences between both groups in 1 day, 6 months, 1 year and 2 years postoperative (p>0.05). For ODI scores, no significant differences between both groups in 6 months, 1 year and 2 years postoperative (p>0.05). According to the Macnab criteria, the satisfaction rate of the LA group was 95.46%, whereas that in the GA group was 100%. Local anesthesia technique had achieved good clinical efficacy as GA anesthesia technique for L4-5-disc herniation treated. Compared with GA, LA had the advantages of shorter operative time, lower blood loss and shorter length of hospital stay. Moreover, LA provided a better clinical outcome in short term. Nevertheless, case selection for each anesthesia technique will be an important key success factor for good results. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The outcomes of revision minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and lateral lumbar interbody fusion (LLIF) have not been compared in the literature thus far. The purpose of this study is to compare perioperative and patient-reported outcome (PRO) data of revision MIS-TLIF and LLIF. This study is a retrospective cohort study. Patients undergoing elective revision MIS-TLIF and LLIF were identified from a prospective single surgeon registry and grouped into cohorts based on surgical approach. Only patients undergoing fusions at spinal levels accessible through both MIS-TLIF and LLIF were included. In total, 102 patients were included, with 29 MIS-TLIF patients and 73 LLIF patients. Outcome measures were perioperative data, minimal clinically important difference (MCID) achievement rates), and PROs including Veterans Rand-12 Physical and Mental Composite Score (VR-12 PCS, MCS), Patient-Reported Outcome Measurement Information System-physical function (PROMIS-PF), Patient-Health Questionnaire-9 (PHQ-9), Visual Analog Scale-Back and Leg Pain (VAS-BP, LP), and Oswestry Disability Index (ODI). Demographics, perioperative data, and PROs were obtained from the registry and compared through independent samples t-tests or chi-square tests. Improvements in PROs by six weeks and final follow-up were tabulated. Postoperative PROs and changes in PROs were compared through multivariable linear regression to account for age differences. MCID achievement rates were calculated for each group by comparing changes in PROs to thresholds reported in prior literature. MCID achievement rates were then compared between groups using multivariable logistic regression. Patients undergoing LLIF were significantly older (58.7 years) than patients undergoing MIS-TLIF (54.0 years) (p=0.047), but there were no other demographic differences between groups (p≥0.111, all). LLIF patients consumed more narcotics on postoperative day 0 (p=0.035), while there were no other differences in perioperative data. There were no significant differences in baseline PROMs (p≥0.059, all). When controlling for differences in age, there were no differences in 6-week postoperative and final follow-up PROMs (p≥ 0.061, all). The LLIF group reported greater average improvement in VAS-LP scores by six weeks postoperatively compared to the MIS-TLIF group (p=0.049), while other outcomes were statistically similar (p≥0.098, all). The LLIF group also reported greater average final follow-up improvements in PROMIS-PF scores (p=0.003), and similar final follow-up improvements otherwise (p≥0.086, all). There were no significant differences in MCID achievement of any outcome overall (p≥0.052, all). When controlling for age, revision LLIF patients reported earlier and greater reduction in leg pain by six weeks, with similar magnitudes of improvement by final follow-up and greater improvement in physical function at final follow-up. Overall, there were no differences in patients achieving clinically significant improvements in any outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Use of Spinal Cord Stimulation (SCS) as a treatment for chronic pain has been historically designated for patients who have had at least one prior spinal surgery. Considering the opioid drug crisis and the often-mixed clinical success of conservative treatment approaches and invasive back surgery procedures, there is growing interest in utilizing SCS in chronic pain patients who have not yet undergone previous surgical intervention.1-4 Recent SCS devices offer substantially more novel technological capabilities and neurostimulative approaches than older-generational SCS systems. Correspondingly, interventional treatment approaches capable of multimodal therapeutic strategies are now actively recommended by pain care advocates.5, 6 Here, we describe our clinical assessment of SCS in patients with no prior history of surgery implanted with a device capable of customizable programming engaging multiple mechanisms of action in a prospective, multicenter, randomized controlled trial (RCT) compared with Conventional Medical Management (CMM). N/A N/A N/A This is a prospective, multicenter randomized, controlled study (SOLIS) that compares the therapeutic effectiveness of SCS versus CMM only in patients with chronic low back and/or leg pain with no prior spinal surgery (Clinicaltrials.gov: NCT04676022). As such, enrolled NSBP patients who meet inclusion criteria are randomized to SCS combined with CMM (SCS + CMM arm) or a CMM-only arm. Those selected to receive SCS are implanted with a multimodal SCS system capable of engaging multiple mechanisms of action (Wavewriter Systems, Boston Scientific). Key inclusion criteria include diagnosis of chronic low back pain, with or without leg pain, for ≥6 months, and documented care of chronic pain for ≥90 days. The primary endpoint is responder rate (≥ 50% reduction in pain) with no increase in baseline opioid medications to treat pain at 3-months following treatment activation. Other secondary and/or exploratory measures include Percent Pain Relief, Quality-of-Life (SF-36; EQ-5D-5L), Treatment Satisfaction (TSQM-9m), Disability (Oswestry Disability Index, ODI), and Safety Outcomes. One hundred and twenty-eight treatment-activated study participants were randomized (63-subjects to the SCS + CMM arm and 65 subjects to the CMM-only arm). Primary endpoint analysis demonstrated that multimodal SCS combined with CMM was superior to CMM alone (p<0.0001) in treating NSBP patients at 3-months follow-up on the basis of obtained responder rates (SCS + CMM: 89.5% [51/57] versus CMM: 8.1% [5/62]). Assessment of disability in those randomized to the multimodal SCS + CMM arm indicated a 28-point reduction in ODI score in comparison to a 7-point reduction in those randomized to CMM only. Out to 12-months follow-up: a high profound responder rate (≥80% pain relief) of 51.2%; significant improvement in disability (Δ25-point ODI decrease vs Baseline); ≥21.1% improvement (EQ-5D-5L). Subjects randomized to CMM who crossed over to SCS+CMM arm achieved comparable results at long-term follow-up. The data obtained in this RCT demonstrates that SCS combined with CMM is effective in treating chronic pain in patients with no prior back surgery (vs CMM alone) as demonstrated by clinically significant improvements in chronic pain, disability, and quality-of-life. Given the prevalence of nonsurgical, refractory back pain and the increasing economic and societal burden it poses, providing SCS as an additional tool within the therapeutic armamentarium for chronic pain represents a key opportunity to address a clinically important need. WaveWriter SCS system (Boston Scientific) (Investigational/Not Approved). [ABSTRACT FROM AUTHOR]

Surgical counseling enables shared decision-making (SDM) by improving patients' understanding. To provide answers to frequently asked questions (FAQs) in minimally invasive lumbar spine surgery. Retrospective review of prospectively collected data. Patients who underwent primary tubular minimally invasive lumbar spine surgery in form of transforaminal lumbar interbody fusion (MI-TLIF), decompression alone, or microdiscectomy and had a minimum of 1-year follow-up. (1) Surgical (radiation exposure and intraoperative complications) (2)Immediate postoperative (length of stay [LOS] and complications) (3) Clinical outcomes (Visual Analog Scale- back and leg, VAS; Oswestry Disability Index, ODI; 12-Item Short Form Survey Physical Component Score, SF-12 PCS; Patient-Reported Outcomes Measurement Information System Physical Function, PROMIS PF; Global Rating Change, GRC; return to activities; complications/reoperations) The outcome measures were analyzed to provide answers to ten FAQs that were compiled based on the authors' experience and a review of literature. Changes in VAS back, VAS leg, ODI, and SF-12 PCS from preoperative values to the early (<6 months) and late (> 6 months) postoperative time points were analyzed with Wilcoxon Signed Rank Tests. % of patients achieving minimal clinically important difference (MCID) for these patient-reported outcome measures (PROMs) at the two time points was evaluated. Changes in PROs from preoperative values too early (<6 months) and late (≥6 months) postoperative time points were analyzed within each of the three groups. Percentage of patients achieving MCID was also evaluated. Three hundred sixty-six patients (104 TLIF, 147 decompression, 115 microdiscectomy) were included. The following FAQs were answered: (1) Will my back pain improve? Most patients report improvement by >50%. About 60% of TLIF, decompression, and microdiscectomy patients achieved MCID at ≥6 months. (2) Will my leg pain improve? Most patients report improvement by >50%. 56% of TLIF, 67% of decompression, and 70% of microdiscectomy patients achieved MCID at ≥6 months. (3) Will my activity level improve? Most patients report significant improvement. Sixty-six percent of TLIF, 55% of decompression, and 75% of microdiscectomy patients achieved MCID for SF-12 PCS. (4) Is there a chance I will get worse? Six percent after TLIF, 14% after decompression, and 5% after microdiscectomy. (5) Will I receive a significant amount of radiation? The radiation exposure is likely to be acceptable and nearly insignificant in terms of radiation-related risks. (6) What is the likelihood that I will have a complication? 17.3% (15.4% minor, 1.9% major) for TLIF, 10% (9.3% minor and 0.7% major) for decompression, and 1.7% (all minor) for microdiscectomy (7) Will I need another surgery? Six percent after TLIF, 16.3% after decompression, 13% after microdiscectomy. (8) How long will I stay in the hospital? Most patients get discharged on postoperative day one after TLIF and on the same day after decompression and microdiscectomy. (9) When will I be able to return to work? >80% of patients return to work (average: 25 days after TLIF, 14 days after decompression, 11 days after microdiscectomy). (10) Will I be able to drive again? >90% of patients return to driving (average: 22 days after TLIF, 11 days after decompression, 14 days after microdiscectomy). These concise answers to the FAQs in minimally invasive lumbar spine surgery can be used by physicians as a reference to enable patient education. [ABSTRACT FROM AUTHOR]

Background Context: The indications for surgical intervention of axial back pain without leg pain for degenerative lumbar disorders have been limited in the literature, as most study designs allow some degree of leg symptoms in the inclusion criteria.Purpose: To determine the outcome of surgery (decompression only vs. fusion) for pure axial back pain without leg pain.Study Design/setting: Prospectively collected data in the Michigan Spine Surgery Improvement Collaborative (MSSIC).Patient Sample: Patients with pure axial back pain without leg pain underwent lumbar spine surgery for primary diagnoses of lumbar disc herniation, lumbar stenosis, and isthmic or degenerative spondylolisthesis ≤ grade II.Outcome Measures: Minimally clinically important difference (MCID) for back pain, Numeric Rating Scale of back pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), MCID of PROMIS-PF, and patient satisfaction on the North American Spine Surgery Patient Satisfaction Index were collected at 90 days, 1 year, and 2 years after surgery.Methods: Log-Poisson generalized estimating equation models were constructed with patient-reported outcomes as the independent variable, reporting adjusted risk ratios (RRadj).Results: Of the 388 patients at 90 days, multi-level versus single level lumbar surgery decreased the likelihood of obtaining a MCID in back pain by 15% (RRadj=0.85, p=.038). For every one-unit increase in preoperative back pain, the likelihood for a favorable outcome increased by 8% (RRadj=1.08, p<.001). Of the 326 patients at 1 year, symptom duration > 1 year decreased the likelihood of a MCID in back pain by 16% (RRadj=0.84, p=.041). The probability of obtaining a MCID in back pain increased by 9% (RRadj=1.09, p<.001) for every 1-unit increase in baseline back pain score and by 14% for fusions versus decompression alone (RRadj=1.14, p=.0362). Of the 283 patients at 2 years, the likelihood of obtaining MCID in back pain decreased by 30% for patients with depression (RRadj=0.70, p<.001) and increased by 8% with every one-unit increase in baseline back pain score (RRadj=1.08, p<.001).Conclusions: Only the severity of preoperative back pain was associated with improvement in MCID in back pain at all time points, suggesting that surgery should be considered for selected patients with severe axial pain without leg pain. Fusion surgery versus decompression alone was associated with improved patient-reported outcomes at 1 year only, but not at the other time points. [ABSTRACT FROM AUTHOR]

Background Context: Transforaminal lumbar interbody fusion (TLIF) with bilateral pedicle screw fixation (BPSF) is an effective treatment for lumbar foraminal stenosis (LFS). However, the effects of TLIF with unilateral pedicle screw fixation (UPSF) on LFS treatment have not been clearly elucidated.Purpose: We conducted this study to compare clinical outcomes and radiographic results of TLIF with UPSF and BPSF 2 years after the surgical treatment.Design: Prospective randomized study.Patient Sample: This study included 23 patients undergoing TLIF with UPSF and 25 patients undergoing TLIF with BPSF.Outcome Measures: Clinical outcomes were evaluated by visual analog scale (VAS) for low back pain and leg pain and Oswestry Disability Index (ODI) score. Radiographic outcomes included foraminal height, disc space height, segmental lordosis, and final fusion rates.Methods: The clinical and radiographic outcomes were compared between the UPSF and BPSF group. The postoperative improvements were evaluated in either group. Intraoperative data such as duration of operation and estimated blood loss were collected. This study was registered at clinicaltrials.gov.Results: Analysis of the VAS and ODI scores showed significant improvements in clinical outcomes within each group. No significant differences between the 2 groups were noted in the improvements of the VAS and ODI scores. The mean operative duration and blood loss were significantly greater in the BPSF group than in the UPSF group. There were significant improvements in the height of the foramen and intervertebral space and segmental lordosis in both groups, while there was no significant difference between the groups in amount of the improvements. No significant difference was found in the final fusion rates.Conclusions: TLIF is an appropriate procedure for LFS treatment. With balanced intervertebral support using a cage, UPSF could achieve similar and satisfactory effects on lumbar segmental stability and fusion compared to BPSF. The unilateral approach appears to be associated with slightly shorter operative time and less blood loss. [ABSTRACT FROM AUTHOR]

Background: Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.Purpose: To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.Study Design/setting: Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020).Outcome Measures: The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.Methods: PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.Results: We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured.Conclusions: We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers. [ABSTRACT FROM AUTHOR]

Novel porous structures in polymer or metal spinal interbody fusion devices have been developed to create a more favorable environment to promote segmental stability and fusion. Surgeons performing lateral lumbar interbody fusion (LLIF) can choose from several interbody implant designs, including those with solid or porous structures made of polyetheretherketone (PEEK) or titanium alloy (Ti). LLIF patients have shown a high success rate of fusion in long-term follow-up, but limited data exist on the influence of implant design on clinical and radiographic outcomes from prospective, comparative clinical studies. To compare the early clinical and radiographic outcomes of smooth PEEK (SP), 3D-printed porous Ti (PTi), and porous PEEK (PP) interbody implants in subjects who undergo LLIF surgery at one or two levels. Prospective, comparative multi-center study. The study included interim results of 117 subjects (300 planned) across 16 US sites who underwent LLIF surgery using SP (n=53), PTi (n=35), or PP (n=29) for degenerative spinal conditions. VAS back and leg pain, and ODI. Radiographic outcomes including fusion assessed with CT. Subjects undergoing one- or two-level LLIF surgery with SP, PTi, or PP interbody implants with allograft cancellous chips with autologous bone marrow aspirate or allograft cellular bone matrix were included in the study. Subjects were excluded if they had BMP or synthetic bone graft substitutes used; prior fusion at treated levels; release of the ALL or posterior osteotomy; deformity surgery; and/or history of disease(s) or actively receiving treatment(s) that may impact bone healing. Subjects with a 6-month CT follow-up were included for analysis. Fusion was reviewed by three spine surgeons, while implant condition and subsidence were assessed by an independent core lab. A total of 117 subjects were included, 60% of patients were female, mean age at surgery was 64.7 years, and mean body mass index was 31.5 kg/m2. Baseline demographics were similar when compared between groups (all p>0.05). The most common indication in all three groups was degenerative spondylolisthesis (80%) and the most treated level was L4-L5 (74%); both p>0.05. Operative times (anterior: 62.4 min and posterior: 75.8 min), estimated blood loss (anterior: 60.4 ml and posterior: 73.5 ml), and length of stay (2.1 days) were similar between groups; all p>0.05. At 6 months postop, mean back pain improved by 4.0 (SP), 4.9 (PTi), and 3.5 (PP), and mean worse leg pain improved by 5.7 (SP), 4.6 (PTi), and 3.9 (PP). Mean ODI score also improved from baseline to 6 months postoperative by 20.5 (SP), 25.4 (PTi), and 20.6 (PP). There was no significant difference in mean improvement of clinical outcomes between groups; all p>0.05. At 6 months follow-up, the fusion rates by level were significantly higher in the PTi (n=41) group with 82.9% fused (p<0.05), after controlling for biologic type, compared with SP (n=62) and PP (n=32) groups with 32.3% and 40.6% fusion rates, respectively. No incidence of implant migration or subsidence was reported in any group. Results of this interim analysis show that LLIF surgery using either SP, PTi, or PP interbody implants led to postoperative improvement in clinical outcomes, including back pain, leg pain, and disability. Fusion rate at 6 months was significantly higher in the PTi group compared with SP and PP. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Lumbar interbody fusion (LIF) is a surgical treatment for degenerative diseases of the lumbar spine. Decompression of neural elements can be achieved directly via posterior approaches, or indirectly through anterior approaches. Though direct decompression through posterior approaches are traditionally used, indirect decompression through anterior approaches and restoration of anatomical disc height with large implants is also well described. To date, there is limited comparative evidence supporting the superiority of one surgical approach over another in terms of long-term clinical outcomes. Our objective is to compare long-term (>1 year) outcomes between anterior (indirect decompression) and posterior (direct decompression) approaches to lumber interbody fusion (LIF) surgery by means of a matched cohort using a nationwide, multicenter observational registry. This is a one-to-one propensity score matched analysis using data from the Canadian Spine Outcomes and Research Network national registry, a nationwide multicentre database compiling prospectively collected data from 18 tertiary care academic and nonacademic hospitals across Canada. Data were collected for adult patients with a degenerative diagnosis who underwent anterior or posterior LIF between January 1, 2015, and February 15, 2022. Patient-reported outcome measures (PROMs) were compared and included Oswestry Disability Index (ODI), the 12-item Short-Form Health Survey (SF)-12 survey, and numerical rating scales (NRS) for leg and back pain at 12 months and 24 months after surgery. Adverse events were also reported according to a standardized protocol. Baseline variables were used in a logistic regression model for calculating the propensity score for being in the anterior or posterior cohort. There were 1,339 patients who met inclusion criteria. Sixty-seven patients were in the anterior cohort and 1,272 were in the posterior cohort. Before matching, patients in the anterior cohort were significantly younger and had a lower BMI. Following matching, 55 patient pairs were identified, and the mean (SD) ages were 60 (10.5) and 62 (10.7) years (p=0.25), the mean (SD) BMI 27.8 (5.46) and 27.3 (4.88) kg/m2 (p=0.61), and the proportion of females 56.4% and 54.6% (p=0.84) for anterior and posterior cohorts, respectively. At 1-year follow up, patients in the anterior cohort had significantly less back pain (2 vs 4 NRS, p=0.0086), however this difference did not persist at 2-years of follow-up. Using prospectively collected data from a large nationwide registry in Canada, we demonstrated that anterior LIF through indirect decompression is associated with less back pain at 1-year follow-up compared to the standard posterior (direct decompression) approaches, but at 2-years follow-up both approaches yielded similar pain relief. Taken together, posterior direct decompression and anterior indirect decompression are reliable methods for interbody fusion of the lumbar spine with comparable long term results. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Psychological and behavioral factors are considered major risk factors for poor outcomes after lumbar spine surgery. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment. To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery. Retrospective analysis of prospectively collected registry data. A total of 700 patients (mean age = 60.9 years, 257 females) undergoing surgery for a primary diagnosis of disc herniation, stenosis, spondylolisthesis, pseudoarthrosis, symptomatic mechanical disc collapse, or adjacent segment disease. All patients had to have completed preoperative patient-reported measures for sleep disturbance and depression and preoperative and 12-month patient-reported outcomes. Patient-reported outcomes were disability (Oswestry Disability Index) and back and leg pain intensity (0-10 Numeric Rating Scale). Outcomes were assessed at baseline and at 12 months after surgery. Preoperative sleep disturbance and depression were assessed with 4-item PROMIS short form versions. Established thresholds defined patients with moderate/severe symptoms. We conducted separate regressions to examine the influence of preoperative sleep disturbance and depression on 12-month outcomes. Regressions examined each factor with and without accounting for the other, and in combination as a 4-level variable: 1) moderate/severe sleep disturbance alone, 2) moderate/severe depression alone, 3) both moderate/severe sleep disturbance and depression, 4) no moderate/severe sleep disturbance or depression. Covariates in regression models included age, sex, race, education, insurance, body mass index, smoking status, preoperative opioid use, fusion status, revision status, and preoperative outcome score. In independent models, preoperative sleep disturbance and depression were significantly associated with 12-month outcomes (p < 0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes (p < 0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability (95% CI: 7.4 to 17.8) and 1.5 points higher back (95% CI: 0.8 to 2.3) and leg pain (95% CI: 0.7 to 2.3) compared to patients without moderate/severe sleep disturbance or depression. Preoperative sleep disturbance and depression are independent predictors of 12-month disability and pain when considered in isolation. The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.Purpose: To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.Study Design/ Setting: Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.Patient Sample: Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.Outcome Measures: Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.Methods: Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.Results: In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.Conclusions: Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar canal stenosis due to degenerative lumbar spondylolisthesis is one of the most common indications for lumbar spinal surgery. However, from a long-term perspective, it is still unclear which of these procedures should be performed: decompression, decompression plus fusion, or decompression plus stabilization.Purpose: This study aimed to present the long-term results of a randomized controlled trial of surgery for degenerative spondylolisthesis.Study Design/setting: This is a long-term follow-up of a previously reported randomized controlled trial.Patient Sample: Patients aged ≤75 years with single L4/5 level lumbar canal stenosis caused by degenerative lumbar spondylolisthesis were enrolled at two hospitals from May 1, 2003, to April 30, 2012; the final follow-up was on May 20, 2021.Outcome Measures: The following data were collected: modified Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score for lower back pain, leg pain, and numbness, and scores from eight Short-Form 36 (SF-36) subscales preoperatively, 1 year postoperatively, 5 years postoperatively, and at the final follow-up.Methods: Patients were randomized to undergo decompression alone, decompression plus fusion, or decompression plus stabilization. The primary outcome measure was the change in VAS for lower back pain with secondary outcomes including the modified JOA score, VAS for leg pain, VAS for leg numbness, eight SF-36 subscale scores, and occurrence of reoperation at the last follow-up.Results: Among 85 patients who were randomized, 66 responded to the current survey. The mean follow-up period was 12.3 years. The VAS score for low back pain improvement was not significantly different between the decompression and fusion groups at the mean follow-up of 12.3 years. Of the 12 secondary outcomes, 8 showed no significant difference between decompression and fusion, 12 showed no significant difference between decompression and stabilization, and 10 showed no significant difference between fusion and stabilization.Conclusions: Although additional instrumentation surgery did not significantly improve low back pain at the mean follow-up of 12.3 years compared with decompression alone, fusion surgery provided clinically meaningful improvements in patient-reported vitality, social functioning, role limitations due to personal or emotional problems, and mental health compared with decompression alone.Trial Registration: UMIN000028114. [ABSTRACT FROM AUTHOR]

Background Context: Minimally invasive techniques have recently been developed as alternative treatments to surgical interventions, especially for small or contained herniated disc.Purpose: Aim of our study is to assess the efficacy of the mechanical percutaneous disc decompression (PDD) in comparison with the percutaneous radiofrequency targeted disc decompression (TDD).Study Design: We conducted a single-center noninferiority trial in which patients who had low back pain with radicular leg pain (RLP) from a contained herniated disc were randomly assigned in a 1:1 ratio to undergo either PDD or TDD.Patient Sample: From January 2016 to January 2017 a total of 327 patients were assessed for eligibility of whom 200 underwent randomization in the trial; 100 patients underwent the PDD and 100 underwent the TDD.Outcome Measures: The primary outcome measure was the proportion of patients who reported >50% reduction in Numeric Rating Scale (NRS) leg pain score. Secondary outcome measure included the proportion of patients who reported >30% improvement in Oswestry Disability Index (ODI) score.Methods: Outcomes of this trial were measured with the use of patient-reported data obtained from validated questionnaires to assess the low back pain with RLP before intervention and at 6 and 12 months after interventions. MRI was performed before intervention and at 6 and 12 months after interventions. In addition to NRS and ODI scores, we collected the following data: age, gender, length of hospitalizations and return to work rate.Results: When using an intention to treat analysis with those lost to follow-up and requiring a second procedure counting as failures, there were no statistically significant difference between the two treatment groups in the primary and secondary outcomes at 6 months: >50% reduction in NRS leg pain (PDD vs. TDD)=67% versus 65%; >30% ODI improvement (PDD vs. TDD)=57% versus 55%. Similarly, there were no statistically significant differences between groups in outcomes at 12 months: >50% reduction in NRS leg pain (PDD vs. TDD)=51% (95% CI 41%-60%) versus 40% (95% CI: 30%-49%); >30% ODI improvement (PDD vs. TDD)=42% (95% CI 32%-51%) versus 30% (95% CI: 21%-39%). A nonintention to treat analysis which discounted those lost to follow-up showed the only statistically significant finding was the percentage of those reporting >30% ODI at the 12 month follow-up time, favoring the PDD group: (PDD vs. TDD)=58% (95% CI 46%-69%) versus 42% (95% CI: 22%-43%).Conclusions: PDD and TDD are comparable treatments for patients presenting with low back pain with RLP unresponsive to medical therapy caused by contained disc herniations. [ABSTRACT FROM AUTHOR]

Background Context: Patients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) frequently present with lower extremity neurologic symptoms with or without associated lower back pain. While symptomatic improvement of leg and back pain has been reported, the resolution of back pain when it is a predominant presenting symptom remains underreported following MI-TLIF.Purpose: The purpose of this study was to compare clinical outcomes at 1 year of patients undergoing MI-TLIF with lower extremity neurologic symptoms with and without a significant component of back pain.Study Design: A retrospective review of prospectively collected data from a single surgeon surgical database from 2017 to 2019 was performed.Patient Sample: Fifty one patients undergoing MI-TLIF.Outcome Measures: Self-reported measures included the Oswestry Disability Index (ODI), Visual analog scale back pain (VAS-back), and VAS leg pain (VAS-leg).Methods: Patients were divided into two groups: Leg Pain Predominant (patients reported greater than 50% leg pain upon presentation) and Back Pain Predominant (patients reported 50% or greater back pain). Multivariate analysis was performed to determine differences between groups based upon any significantly baseline characteristics.Results: Preoperative demographic and radiographic outcomes were similar between the two groups. Both groups demonstrated significant improvement in ODI, VAS-Back and VAS-leg at 1-year postoperatively. On multivariate analysis, there were differences in ODI at 1-year, 1-year back pain, and 1-year leg pain between groups with those who initially presented with leg pain having a lower ODI, VAS Back, and VAS leg. Patients who presented with predominantly leg pain were more likely to meet minimal clinically important difference (MCID) criteria for ODI and VAS-back compared to those with predominantly back pain.Conclusion: Following MI-TLIF, patients with lower extremity neurologic symptoms with and without a significant component of back pain have improvements in back pain, leg pain, and ODI regardless of their primary presenting pain complaint; however, patients who presented with predominantly leg pain were more likely to meet MCID criteria for improvement in their back pain and ODI score. [ABSTRACT FROM AUTHOR]

Background Context: The lumbar sinuvertebral nerve (SVN) innervates the outer posterior intervertebral disc (IVD); it is thought to mediate discogenic low-back pain (LBP). Controversy, however, exists on its origins at higher (L1-L2) versus lower (L3-L5) lumbar levels. Additionally, lack of knowledge regarding its foraminal and intraspinal branching patterns and extensions may lead to iatrogenic damage.Purpose: To systematically describe the origins of the L2 and L5 SVNs, their morphological variation in the intervertebral foramen (IVF) and intraspinal distribution.Study Design: Dissection-based study of 20 SVNs with histological confirmation in five embalmed human cadavers.Methods: The origin, branching pattern and distribution of the L2 and L5 SVNs was investigated bilaterally in five human cadavers using dorsal and anterolateral dissection approaches. Parameters studied included somatic and/or autonomic SVN root contributions, foraminal SVN morphology and course, diameter, branching point, intraspinal distribution and IVD innervation pattern. Nerve tissue was confirmed by immunostaining for neurofilament and S100 proteins.Results: The SVN and its origins was identified in all except one IVF at L2 and in all foramina at L5. At L2, the SVN arose in nearly 90% of sides from both somatic and autonomic roots and at L5 in 40% of sides. The remaining SVNs were formed by purely autonomic roots. The SVN arose from significantly more roots at L2 than L5 (3.1 ± 0.3 vs. 1.9 ± 0.3, respectively; p=.022). Four different SVN morphologies could be discerned in the L2 IVF: single filament (22%), multiple (parallel or diverging) filament (33%), immediate splitting (22%) and plexiform (22%) types, whereas the L5 SVN consisted of single (90%) and multiple (10%) filament types. SVN filaments were significantly thicker at L2 than L5 (0.48 ± 0.06 mm vs. 0.33 ± 0.02 mm, respectively; p=.043). Ascending SVN filaments coursed roughly parallel to the exiting spinal nerve root trajectory at L2 and L5. Branching of the SVN into ascending and descending branches occurred mostly intraspinal both at L2 and L5. Spinal canal distribution was also similar for L2 and L5 SVNs. Lumbar posterior IVDs were innervated by the descending branch of the parent SVN and ascending branch of the subjacent SVN.Conclusions: The SVN at L2 originates from both somatic and autonomic roots in 90% of cases and at L5 in 40% of cases. The remaining SVNs are purely autonomic. In the IVF, the L2 SVN is morphologically heterogeneous, but generally consists of numerous filaments, whereas at L5 90% contains a single SVN filament. The L2 SVN is formed by more roots and is thicker than the L5 SVN. Intraspinal SVN distribution is confined to its level of origin; lumbar posterior IVDs are innervated by corresponding and subjacent SVNs (ie, two spinal levels).Clinical Significance: Our findings indicate that L5 discogenic LBP may be mediated both segmentally and nonsegmentally in 40% of cases and nonsegmentally in 60% of cases. Failure of lower lumbar discogenic pain treatment may be the result of only interrupting the nonsegmental pathway, but not the segmental one as well. Relating SVN anatomy to microsurgical spinal approaches may prevent iatrogenic damage to the SVN and the formation of postsurgical back pain. [ABSTRACT FROM AUTHOR]

Background Context: There is apparent causality between chronic infection of the intervertebral disc and its degenerative process. Although disc is considered a sterile tissue, collected samples of uninfected patients sent to culture testing resulted positive.Purpose: The purpose of this study was to analyze the microbiome of the intervertebral disc by using and validating the next-generation sequencing (NGS) molecular test, controlled with tissue culture and clinical presentation of patients.Study Design/setting: Prospective study of consecutive patients in a hospital.Patient Sample: Patients with lumbar disc herniation undergoing open microdiscectomy aging 18 to 65 years.Outcome Measures: NGS, tissue culture METHODS: Subjects undergoing open decompression surgery for lumbar disc herniation were consecutively included and clinically followed for one year. Three samples of the excised herniated disc fragment were sent to tissue culture and another sample of the disc was sent to NGS test for microbiome analysis. Control samples of the ligamentum flavum and deep muscle were collected and sent to culture.Results: A total of 17 patients were included. All patients presented negative cultures of the removed disc samples, as well as negative cultures of muscle and yellow ligament. None of the patients evolved to clinical infection one year after surgery, nor presented significant alteration of laboratory markers. NGS mapped a mean of 14,645 (range 6,540 to 27,176) DNA sequences for each disc sample of each patient. There were a total of 45 different bacteria genera remnants with different amount of DNA sequences detected. There was a mean of 8 (range 3-17) different bacterial elements in each sample of intervertebral disc. Three bacteria were present in all disc samples (Herbaspirillum, Ralstonia, and Burkolderia). Although there were a considerable mean number of bacterial sequences mapped in each disc sample, the amount of sequences related to bacteria was low. Cutibacterium acnes elements was not found in any disc microbiome analysis.Conclusions: NGS has been proven to adequately determine bacterial DNA presence within the intervertebral disc. C. acnes was not isolated in culture neither in microbiome analysis of patients with lumbar disc herniation. We cannot confirm disc sterility since, even if it does not cause infection, there is bacterial or remnant DNA in herniated discs. [ABSTRACT FROM AUTHOR]

Background Context: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown.Purpose: To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology STUDY DESIGN/SETTING: Retrospective Cohort Study PATIENT SAMPLE: Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage OUTCOME MEASURES: Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF) METHODS: Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT.Results: A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p = .017) and SF-12 PCS (41.5 vs. 50.0, p = .035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24).Conclusions: While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar spinal stenosis (LSS) is one of the most common orthopaedic conditions and affects more than half a million people over the age of 65 in the US. Patients with LSS have gait dysfunction and movement deficits due to pain and symptoms caused by compression of the nerve roots within a narrowed spinal canal.Purpose: The purpose of the current systematic review was to summarize existing literature reporting biomechanical changes in gait function that occur with LSS, and identify knowledge gaps that merit future investigation in this important patient population.Study Design/setting: This study is a systematic literature review.Outcome Measures: The current study included biomechanical variables (e.g., kinematic, kinetic, and muscle activity parameters).Methods: Relevant articles were selected through MEDLINE, Scopus, Embase, and Web of Science. Articles were included if they: 1) included participants with LSS or LSS surgery, 2) utilized kinematic, kinetic, or muscle activity variables as the primary outcome measure, 3) evaluated walking or gait tasks, and 4) were written in English.Results: A total of 11 articles were included in the current systematic review. The patients with LSS exhibited altered gait function as compared to healthy controls. Improvements in some biomechanical variables were found up to one year after surgery, but most gait changes were found within one month after surgery.Conclusions: Although numerous studies have investigated gait function in patients with LSS, gait alterations in joint kinetics and muscle activity over time remain largely unknown. In addition, there are limited findings of spinal kinematics in patients with LSS during gait. Thus, future investigations are needed to investigate longer-term gait changes with regard to spinal kinematics, joint kinetics, and muscle activity beyond one month after LSS surgery. [ABSTRACT FROM AUTHOR]

Background Context: There are few studies of the radio-clinical outcomes of cement-augmented cannulated pedicle screw (CPS) fixation in osteoporotic patients.Purpose: To compare the radiological and clinical outcomes between groups receiving cement-augmented CPS and solid pedicle screws (SPS) in lumbar fusion surgery.Study Design/setting: Retrospective comparative study PATIENT SAMPLE: A total of 187 patients who underwent lumbar fusion surgery for degenerative spinal stenosis or spondylolisthesis from 2014 to 2019.Outcome Measures: Radiological evaluation included screw failure, cage failure, rod breakage, and fusion grade at postoperative 6 months and 1 year. Pre- and postoperative visual analog scales for back pain (VAS-BP), leg pain (VAS-LP), Korean Oswestry disability index (K-ODI), and postoperative complications were also compared.Methods: Outcomes of patients with high risk factors for implant failure [old age, osteoporosis, autoimmune disease or chronic kidney disease (CKD)] who underwent open transforaminal lumbar interbody fusion with cement-augmented CPS fixation (Group C, n=55) or SPS fixation (Group S, n=132) were compared.Results: 324 pedicle screws in Group C and 775 pedicle screws in Group S were analyzed. Group C had a significantly higher average age and lower T-score, and included more patients with autoimmune disease and CKD than group S (all p<.05). Clear zones, screw migration and loss of correction were significantly less frequent in Group C (all p<.05). Thirteen screw breakages were observed; they were only in Group C (4.0%) and all were in the proximal of the two holes. Interbody and posterolateral fusion rates were not significantly different. At last follow-up, all clinical parameters including VAS-BP, VAS-LP, and K-ODI scores had improved significantly in both groups. Postoperative complications were not significantly different in the two groups.Conclusion: In lumbar fusion surgery, using cement-augmented CPS in high-risk groups for implant failure could be a useful technical option for reducing acute radiological complications and obtaining clinical results comparable to those obtained using SPS in patients with low risk of implant failure.Level Of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Background Context: Criteria for success after surgical treatment of lumbar spinal stenosis (LSS) have been defined previously; however, there are no clear criteria for failure and worsening after surgery as assessed by patient-reported outcome measures (PROMs).Purpose: We aimed to quantify changes in standard PROMs that most accurately identified failure and worsening after surgery for LSS.Study Design /setting: Retrospective analysis of prospective national spine registry data with 12-months follow-up.Patient Sample: We analyzed 10,822 patients aged 50 years and older operated in Norway during a decade, and 8,258 (76%) responded 12 months after surgery.Outcome Measures (proms): We calculated final scores, absolute changes, and percentage changes for Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for back and leg pain (0-10), and EuroQol-5D (EQ-5D). These 12 PROM derivates were compared to the Global Perceived Effect (GPE), a 7-point Likert scale.Methods: We used ODI, NRS back and leg pain, and EQ-5D 12 months after surgery to identify patients with failure (no effect) and worsening (clinical deterioration). The corresponding GPE at 12-months was graded as failure (GPE=4-7) and worsening (GPE=6-7) and used as an external criterion. To quantify the most accurate cut-off values corresponding to failure and worsening, we calculated areas under the curves (AUCs) of receiver operating characteristics (ROC) curves for the respective PROM derivates.Results: Mean (95% CI) age was 68.3 (68.1 - 68.5) years, and 52% were females. There were 1,683 (20%) failures, and 476 (6%) patients were worse after surgery. The mean (95% CI) pre- and postoperative ODIs were 39.8 (39.5 - 40.2) and 23.7 (23.3 - 24.1), respectively. At 12 months, the mean difference (95% CI) in ODI was 16.1 (15.7 - 16.4), and the mean (95% CI) percentage improvement 38.8% (37.8 - 38.8). The PROM derivates identified failure and worsening accurately (AUC>0.80), except for the absolute change in EQ-5D. The ODI derivates were most accurate to identify both failure and worsening. We found that less than 20% improvement in ODI most accurately identified failure (AUC=0.89 [95% CI: 0.88 to 0.90]), and an ODI final score of 39 points or more most accurately identified worsening (AUC =0.91 [95% CI: 0.90 - 0.92]).Conclusions: In this national register study, ODI derivates were most accurate to identify both failure and worsening after surgery for degenerative lumbar spinal stenosis. We recommend use of ODI percentage change and ODI final score for further studies of failure and worsening in elective spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Spine patients have a higher rate of depression then the general population which may be caused in part by levels of pain and disability from their spinal disease.Purpose: Determination whether improvements in health-related quality of life (HRQOL) resulting from successful spine surgery leads to improvements in mental health.Study Design/setting: The Canadian Spine Outcome Research Network prospective surgical outcome registry.Outcome Measures: Change between preoperative and postoperative SF12 Mental Component Score (MCS). Secondary outcomes include European Quality of Life (EuroQoL) Healthstate, SF-12 Physical Component Score (PCS), Oswestry Disability Index (ODI), Patient Health Questionaire-9 (PHQ9), and pain scales.Methods: The Canadian Spine Outcome Research Network registry was queried for all patients receiving surgery for degenerative thoracolumbar spine disease. Exclusion criteria were trauma, tumor, infection, and previous spine surgery. SF12 Mental Component Scores (MCS) were compared between those with and without significant improvement in postoperative disability (ODI) and secondary measures. Multivariate analysis examined factors predictive of MCS improvement.Results: Eighteen hospitals contributed 3222 eligible patients. Worse ODI, EuroQoL, PCS, back pain and leg pain correlated with worse MCS at all time points. Overall, patients had an improvement in MCS that occurred within 3 months of surgery and was still present 24 months after surgery. Patients exceeding Minimally Clinically Important Differences in ODI had the greatest improvements in MCS. Major depression prevalence decreased up to 48% following surgery, depending on spine diagnosis.Conclusions: Large scale, real world, registry data suggests that successful surgery for degenerative lumbar disease is associated with reduction in the prevalence of major depression regardless of the specific underlaying diagnosis. Worse baseline MCS was associated with worse baseline HRQOL and improved postoperatively with coincident improvement in disability, emphasizing that mental wellness is not a static state but may improve with well-planned spine surgery. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar intervertebral disc herniation (LDH) is a common disease that causes low back pain, radiating leg pain, and sensory impairment. Preclinical studies rely heavily upon standardized animal models of human diseases to predict clinical treatment efficacy and to identify and investigate potential adverse events in human subjects. The current method for making the LDH model involves harvesting the nucleus pulposus (NP) from autologous coccygeal discs and applying to the lumbar nerve roots just proximal to the corresponding dorsal root ganglion. However, this surgical method generates a model that exhibits very different characteristics of disc herniation than that observed in human.Purpose: To produce a rat LDH model that better resembles disc herniation in humans and a standardized and uniform LDH model using Interleukin-1 beta (IL-1β).Study Design: Experimental rat LDH model.Methods: We exposed the L5-6 disc dorsolaterally on the right side through hemi-laminectomy without nerve compression. Herniation was initiated by puncturing the exposed disc with a 30-gauge needle at a depth of 4 mm. Interleukin-1 beta (IL-1β) was injected simultaneously to heighten the pathological processes of disc degeneration, including inflammatory responses, matrix destruction, and herniation of the NP. We performed histological staining to assess morphological changes, immunohistochemistry to analyze inflammation- and pain-related expression within and around the puncture site of the L5-6 disc, and real-time polymerase chain reaction to examine expression of markers for degenerative processes. In addition, we performed locomotor tests on the rats.Results: We found that the IL-1β groups showed that the border between the annulus fibrosis and nucleus pulposus was severely interrupted compared to that of the control (puncture only) group. And, the injection of IL-1β leads to accelerated disc degeneration and inflammation in a more consistent manner in LDH model. Functional deficit was consistently induced by puncturing and injection of IL-1β in the exposed disc.Conclusions: The method proposed here can be used as an index to control the severity of disc degeneration and inflammation through the injected IL-1β concentration concurrent with surgically induced herniation.Clinical Significance: Our proposed model may facilitate research in drug development to evaluate the efficacy of potential therapeutic agents for disc herniation and neuropathic pain and may also be used for nonclinical studies to more accurately assess the effectiveness of various treatment strategies according to the severity of disc degeneration. [ABSTRACT FROM AUTHOR]

Background Context: Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role.Purpose: The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration).Study Design/setting: A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital.Patient Sample: Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208.Outcome Measures: Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery.Methods: The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success.Results: At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF.Conclusions: Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure. [ABSTRACT FROM AUTHOR]

Background Context: The indication to perform a fusion and decompression surgery as opposed to decompression alone for lumbar degenerative spondylolisthesis (LDS) remains controversial. A variety of factors are considered when deciding on whether to fuse, including patient demographics, radiographic parameters, and symptom presentation. Likely surgeon preference has an important influence as well.Purpose: The aim of this study was to assess factors associated with the decision of a Canadian academic spine surgeon to perform a fusion for LDS.Study Design/setting: This study is a retrospective analysis of patients prospectively enrolled in a multicenter Canadian study that was designed to evaluate the assessment and surgical management of LDS.Patient Sample: Inclusion criteria were patients with: radiographic evidence of LDS and neurogenic claudication or radicular pain, undergoing posterior decompression alone or posterior decompression and fusion, performed in one of seven, participating academic centers from 2015 to 2019.Outcome Measures: Patient demographics, patient-rated outcome measures (Oswestry Disability Index [ODI], numberical rating scale back pain and leg pain, SF-12), and imaging parameters were recorded in the Canadian Spine Outcomes Research Network (CSORN) database. Surgeon factors were retrieved by survey of each participating surgeon and then linked to their specific patients within the database.Methods: Univariate analysis was used to compare patient characteristics, imaging measures, and surgeon variables between those that had a fusion and those that had decompression alone. Multivariate backward logistic regression was used to identify the best combination of factors associated with the decision to perform a fusion.Results: This study includes 241 consecutively enrolled patients receiving surgery from 11 surgeons at 7 sites. Patients that had a fusion were younger (65.3±8.3 vs. 68.6±9.7 years, p=.012), had worse ODI scores (45.9±14.7 vs. 40.2±13.5, p=.007), a smaller average disc height (6.1±2.7 vs. 8.0±7.3 mm, p=.005), were more likely to have grade II spondylolisthesis (31% vs. 14%, p=.008), facet distraction (34% vs. 60%, p=.034), and a nonlordotic disc angle (26% vs. 17%, p=.038). The rate of fusion varied by individual surgeon and practice location (p<.001, respectively). Surgeons that were fellowship trained in Canada more frequently fused than those who fellowship trained outside of Canada (76% vs. 57%, p=.027). Surgeons on salary fused more frequently than surgeons remunerated by fee-for-service (80% vs. 64%, p=.004). In the multivariate analysis the clinical factors associated with an increased odds of fusion were decreasing age, decreasing disc height, and increasing ODI score; the radiographic factors were grade II spondylolisthesis and neutral or kyphotic standing disc type; and the surgeon factors were fellowship location, renumeration type and practice region. The odds of having a fusion surgery was more than two times greater for patients with a grade II spondylolisthesis or neutral and/or kyphotic standing disc type (opposed to lordotic standing disc type). Patients whose surgeon completed their fellowship in Canada, or whose surgeon was salaried (opposed to fee-for-service), or whose surgeon practiced in western Canada had twice the odds of having fusion surgery.Conclusions: The decision to perform a fusion in addition to decompression for LDS is multifactorial. Although patient and radiographic parameters are important in the decision-making process, multiple surgeon factors are associated with the preference of a Canadian spine surgeon to perform a fusion for LDS. Future work is necessary to decrease treatment variability between surgeons and help facilitate the implementation of evidence-based decision making. [ABSTRACT FROM AUTHOR]

Background Context: Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).Purpose: To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).Study Design/setting: Prospective cohort study.Patient Sample: One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.Outcome Measures: Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.Methods: A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.Results: The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.Conclusions: LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS. [ABSTRACT FROM AUTHOR]

Background Context: There has been limited research on the association between hand grip strength (HGS) as one of the diagnostic criteria for sarcopenia and surgical outcomes of lumbar spinal stenosis (LSS).Purpose: We aimed to determine the effect of HGS on surgical outcomes and risk of fall in patients with LSS.Study Design: This is a retrospective observational study.Patient Sample: We included 200 patients who underwent spinal surgery for LSS.Outcome Measures: We recorded clinical outcome parameters, including Oswestry Disability Index (ODI), Euro-QOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain. To assess the risk of fall we used HGS and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, sit-to-stand test).Materials and Methods: ODI, EQ-5D, and VAS scores for back and leg pain were assessed preoperatively and 1 year after surgery. The four functional mobility tests were assessed at each time point during the 1-year follow-up period to assess the risk of fall in patients with LSS. We divided the patient cohort according to sex and allocated them into two different groups based on HGS: high HGS (≥26 kg for men, n=26; ≥18 kg for women, n=35), and low HGS (<26 kg for men, n=48; <18 kg for women, n=91). The pre- and postoperative ODI, EQ-5D, and VAS scores for back and leg pain, as well as the functional mobility test results, and demographic data were compared between the two groups using independent t tests. Correlations between HGS and clinical outcome parameters were analyzed using Pearson correlation.Results: In women and men, HGS correlated with the preoperative/postoperative ODI (r1=-0.217/r2=-0.345 in women, and r1=-0.384/r2=-0.411 in men) and EQ-5D scores (r1=0.190/r2=0.309 in women, and r1=0.373/r2=0.467 in men). HGS also correlated with the four postoperative results for the functional mobility tests: alternative step test (r=-0.238 in women, r=-0.431 in men), six-meter walk test (r=-0.232 in women, r=-0.282 in men), timed up and go test (r=-0.285 in women, r=-0.359 in men), and sit-to-stand test (r=-0.238 in women, r=-0.251 in men). The preoperative and postoperative ODI and EQ-5D scores in the high HGS group were superior to those in the low HGS group. Among the four functional mobility tests, preoperative and postoperative six-meter walk test results showed improvements in the high HGS group.Conclusions: Considering the multifactorial nature of falls, HGS may be a useful surrogate marker for predicting the risk of falls and clinical outcomes in patients with LSS. [ABSTRACT FROM AUTHOR]

Background Context: Spinopelvic parameters indicative of sagittal imbalance include a pelvic tilt (PT) greater than 20° and a mismatch between pelvic incidence (PI) and lumbar lordosis (LL) greater than 10°. However, unlike in fusion surgery, the relationship between spinopelvic parameters and patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery for neurologic symptoms is less clear.Purpose: To determine whether PROMs are affected by the amount of residual (postoperative) PI-LL mismatch or PT in patients undergoing one- to three-level lumbar decompression surgeries.Design: Retrospective cohort study (Level of Evidence: III).Patient Sample: Patients undergoing between one to three levels of lumbar decompression surgery at a single, academic institution.Outcome Measures: PROMs-including the PCS-12, MCS-12, ODI, and VAS Back and Leg pain scores-and radiographic measurements of spinopelvic parameters.Methods: Patients were separated into groups based on a postoperative PI-LL mismatch of ≤10° or >10° and a postoperative PT<20° or ≥20°. Absolute PROM scores, the recovery ratio (RR) and the percentage of patients achieving Minimum Clinically Important Difference between groups were compared and a multiple linear regression analysis was performed.Results: A total of 167 patients were included, with 27 patients in the PI-LL>10° group and 91 patients in the PT≥20° group. All groups exhibited significant improvement after surgery for each PROM included (p<.05) except for MCS-12 scores in the PI-LL≤10° group and both PT groups. Comparing between groups, all patients were similar with respect to preoperative scores, postoperative scores, change in scores, recovery ratios, and percentage change in Minimum Clinically Important Difference, except that patients with PT≥20° had higher pre- and postoperative VAS Back scores (p=.036 and p=.024, respectively). With multiple linear regression, postoperative PI-LL>10° and PT≥20° were not significant predictors of worse outcomes for any measured PROM.Conclusions: Patients with postoperative measurements PI-LL>10° and PT≥20° without instability had similar PROMs at 1 year after limited lumbar decompression when compared to patients without a spinopelvic mismatch. [ABSTRACT FROM AUTHOR]

Background Context: Addition of interbody fusion via a transforaminal approach (TLIF) has become a popular surgical option for treatment of degenerative lumbar conditions. Although technically more complicated than posterolateral fusion surgery (PLF), it has been suggested that TLIF provides superior immediate stability and protects against early pedicle screw loosening. This theory has never been formally examined in a clinical study.Purpose: To determine the impact of TLIF on early pedicle screw loosening and radiographic fusion rates compared with PLF using pedicle screws alone in the treatment of single level lumbar degenerative conditions.Study Design: Retrospective computed tomography (CT) based review.Patient Sample: One hundred ninety-three patients underwent TLIF+PLF with local autograft bone or PLF alone with local autograft bone.Outcome Measures: Radiographic fusion rates and screw loosening were measured at 6 and 12 months using strict CT criteria. Patient self-reported outcome measures included Visual Analog Scale for low back pain and leg pain and Oswestry Disability Index.Methods: Postoperative thin-cut CTs were examined for pedicle screw loosening and radiographic fusion status. Early screw loosening rates were determined using 6-month postoperative CT, whereas radiographic fusion rates were determined using 12-month postoperative CT. One-way analysis of variance was used to determine significant differences in mean outcome scores and other continuous measures between groups at baseline and follow-up. Chi-square test of independence or Fisher's exact test was used to compare proportions between groups on categorical measures.Results: Eighty-three patients underwent TLIF+PLF (Group A) and 115 patients underwent PLF alone (Group B). At 6-month follow-up, loosening was observed in 49 of 792 total screws (6.19%). Of Group A, 7.23% of patients demonstrated loosening of one or more screws compared with 18.3% of Group B (Chi-Square value 4.98; p=.0256). Six-month radiographic fusion rates were 36.1% in Group A versus 44.3% in Group B. Twelve-month radiographic fusion rates increased to 58.6% in Group A versus 73.1% in Group B. Among Group A patients not yet fused at 6 months, screw loosening was associated with a 0% rate of radiographic fusion at 12 months versus 41.2% without screw loosening. Rates for Group B were 6.25% and 70.3%, respectively. Patient age was a significant independent predictor of loosening (p=.0336).Conclusions: TLIF appears to have a protective effect, reducing rates of early screw loosening by approximately 60% versus PLF. However, this effect appears independent of actual overall radiographic fusion rates which may be approximately 20% lower with TLIF at 12 months. TLIF may have advantages in patients where early loosening is a particular concern, for example, in the setting of increased patient age. [ABSTRACT FROM AUTHOR]

Background Context: Minimum clinically important difference (MCID) for patient-reported outcome measures is commonly used to assess clinical improvement. However, recent literature suggests that an absolute point-change may not be an effective or reliable marker of response to treatment for patients with low or high baseline patient-reported outcome scores. The multitude of established MCIDs also makes it difficult to compare outcomes across studies and different spine surgery procedures.Purpose: To determine whether a 30% reduction from baseline in disability and pain is a valid method for determining clinical improvement after lumbar spine surgery.Study Design: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.Patient Sample: There were 23,280 participants undergoing elective lumbar spine surgery for degenerative disease who completed a baseline and follow-up assessment at 12 months.Outcome Measures: Patient-reported disability (Oswestry Disability Index [ODI]), back and leg pain (11-point Numeric Rating Scale [NRS]), and satisfaction (NASS scale).Methods: Patients completed baseline and a 12-month postoperative assessment to evaluate the outcomes of disability, pain, and satisfaction. The change in ODI and NRS pain scores was categorized as met (≥30%) or not met (<30%) percent reduction MCID. The 30% reduction from baseline was compared with a wide range of well-established absolute point-change MCID values. The relationship between 30% reduction and absolute change values and satisfaction were primarily compared using receiver operating characteristic (ROC) curves, area under the curve (AUROC), and logistic regression analyses. Analyses were conducted for overall scores and for disability and pain severity categories and by surgical procedure.Results: Thirty percent reduction in ODI and back and leg pain predicted satisfaction with more accuracy than absolute point-change values for the total population and across all procedure categories (p<.001), except for when compared with the highest absolute point-change threshold for leg pain (3.5-point reduction). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 21.8%) and bed-bound disability (ODI 81%-100%: 13.9%) categories. For pain, there was a 3.4%-12.4% and 1.3%-9.8% AUROC difference for no/mild back and leg pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.Conclusions: A 30% reduction MCID either outperformed or was similar to absolute point-change MCID values. Results indicate that a 30% reduction (baseline to 12 months after surgery) in disability and pain is a valid method for determining clinically relevant improvement in a broad spine surgery population. Furthermore, a 30% reduction was most accurate for patients in the lowest and highest disability and lowest pain severity categories. A 30% reduction MCID allows for a standard cut-off for disability and pain that can be used to compare outcomes across various spine surgery procedures. [ABSTRACT FROM AUTHOR]

Background Context: Due to poor bone stock in the elderly, a noninstrumented fusion is commonly performed in Scandinavia when instability is present. Allograft bone is often used as graft extender with consequent low fusion rates. The use of 15 amino acid residue (ABM/P-15) has shown superior fusion rates in dental and cervical spinal surgery but no clinical studies have been conducted in noninstrumented lumbar fusion surgery.Purpose: To evaluate patient reported outcomes (PROs) and the intertransverse fusion rate in noninstrumented posterolateral fusion with either ABM/P-15 or allograft.Study Design: Double-blind randomized clinical trial.Patient Sample: Patients 60 years or older with degenerative spondylolisthesis undergoing decompression and noninstrumented posterolateral fusion.Outcome Measures: Visual analog scales for back and leg pain, Oswestry Disability Index and EuroQoL-5D.Methods: One hundred one patients were enrolled in the study and randomized 1:1 to either ABM/P-15 (mixed 50/50, 5cc/level) or allograft bone (30 g/level), both mixed with local bone graft. PROs were collected at baseline and at 12 and 24 months after surgery. The patients underwent 1-year postoperative fine cut computed tomography-scans (0.9 mm) with reconstructions, independently evaluated by three reviewers. Fusion status was concluded by consensus of two of the three as "fusion" or "no fusion."Results: There were 49 patients available for analysis in both cohorts. The two groups were similar in terms of sex distribution, age, and number of levels fused. The fusion rate was significantly higher in the ABM/P-15 group with 50% fused compared with 20% in the allograft group. PROs at baseline and at all follow-up time points were similar between the two groups.Conclusions: Patients undergoing noninstrumented posterolateral fusion augmented with ABM/P-15 had a statistically significantly higher fusion rate compared with allograft when evaluated with postoperative fine cut computed tomography-scans (0.9 mm) with reconstructions. However, this did not translate to better clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Context: Prognostic models including early postoperative variables may provide optimal estimates of long-term outcomes and help direct postoperative care.Purpose: To develop and validate prognostic models for 12-month disability, back pain, leg pain, and satisfaction among patients undergoing microdiscectomy, laminectomy, and laminectomy with fusion for degenerative lumbar conditions.Study Design/setting: Retrospective cohort study using the Quality Outcomes Database.Patient Sample: Patients receiving elective lumbar spine surgery due to degenerative spine conditions.Outcome Measures: Oswestry Disability Index, pain numerical rating scale, and NASS Patient Satisfaction Index.Methods: Prognostic models were developed using proportional odds ordinal logistic regression using patient characteristics and baseline and 3-month patient-reported outcome scores. Models were fit for each outcome stratified by type of surgical procedure. Adjusted odds ratio and 95% confidence intervals were reported for all predictors by procedure. Models were internally validated using bootstrap resampling. Discrimination was reported as the c-index and calibration was presented using the calibration slope. We compared the performance of models with and without 3-month patient-reported variables. This research was supported by the Foundation for Physical Therapy's Center of Excellence in Physical Therapy Health Services, and Health Policy Research and Training grant.Results: The sample consisted of 5,840 patients receiving a microdiscectomy (n=2,085), laminectomy (n=1,837), or laminectomy with fusion (n=1,918). The 3-month Oswestry score was the strongest and most consistent predictor associated with 12-month outcomes. All prognostic models performed well with overfitting-corrected c-index values ranging from 0.718 to 0.795 and all optimism corrected calibration slopes over 0.92. The increase in c-index values ranged from 0.09 to 0.21 when adding 3-month patient-reported outcome scores.Conclusions: Models had good discrimination and were well calibrated for estimating 12-month disability, back pain, leg pain, and satisfaction. Patient-reported outcomes at 3 months after surgery, especially 3-month Oswestry scores, improved the 12-month performance of all prognostic models beyond using only baseline variables. [ABSTRACT FROM AUTHOR]

Background Context: Despite the growing senior population within the United States, there is a lack of consensus regarding the safety and efficacy of performing lumbar spinal fusion for this population.Purpose: To evaluate the clinical and radiographic outcomes in different age cohorts following lumbar spinal fusion.Study Design: Retrospective cohort analysis.Patient Sample: Analysis of 1,184 patients who underwent posterolateral lumbar fusion from 2011 to 2018. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, had a lumbar fracture, tumor, or infection, or had fusions involving the thoracic spine, high-grade spondylolisthesis, or concomitant deformity. Of the 1,184 patients, 850 patients were included. Patients were divided into three roughly equal groups for analysis: young (18-54 years), middle-aged (55-69 years), and senior (≥70 years).Outcome Measures: Visual Analog Scale Back/Leg pain, and Oswestry Disability Index (ODI) were collected, and achievement of minimal clinically important difference was evaluated. Lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and PI-LL difference were measured on radiographs. Rates of postoperative complications were analyzed.Methods: Several radiographic parameters were measured using plain radiographs obtained at preoperative, immediately postoperative (standing radiographs performed on postoperative day 1), and most recent follow-up visits. Preoperative and final patient-reported outcomes, along with demographic information, were obtained all patients. Binary outcome variables were compared between groups with multivariate logistic regression, and continuous outcome variables were compared using multivariate linear regression, with age 18 to 54 years used as the reference. Multivariate regressions were used to compare outcomes between cohorts while controlling baseline characteristics.Results: A total of 850 patients were included; 330 young (38.80%), 317 middle-aged (37.30%), and 203 senior (23.90%). Seniors had higher postoperative length of stay compared to younger patients (p<.001). Younger patients had worse final ODI scores compared to middle-aged patients (p=.002). Seniors had higher rates of proximal ASD (p=.002) compared to young patients. There was no difference in achievement of minimal clinically important differences (MCID) between all three groups.Conclusions: Senior patients have significant improvement in patient-reported clinical outcomes, despite having greater comorbidities, and longer length of stay. However, given a general lack of achievement of MCID across all cohorts, these findings suggest the need for a critical re-evaluation of the role of lumbar spinal fusion in the management of patients with refractory radiculopathic and/or neurogenic claudication symptoms. [ABSTRACT FROM AUTHOR]