Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXTPreoperative 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.PURPOSEThe 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.STUDY DESIGN/SETTINGPatients 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.PATIENT SAMPLEPatients 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.OUTCOME MEASURESThe 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.METHODSExpectations 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.RESULTSThree 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.CONCLUSIONPreoperative 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.     

Lumbar degenerative spondylolisthesis: factors associated with the decision to fuse

BACKGROUND CONTEXTThe 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.PURPOSEThe 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/SETTINGThis 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 SAMPLEInclusion 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 MEASURESPatient 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.METHODSUnivariate 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.RESULTSThis 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.CONCLUSIONSThe 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.     

Degenerative spondylolisthesis of the cervical spine: analysis of 58 patients treated with anterior cervical decompression and fusion

Background contextDegenerative spondylolisthesis has been well described as a disorder of the lumbar spine. Few authors have suggested that a similar disorder occurs in the cervical spine. To our knowledge, the present study represents the largest series of patients with long-term follow-up who were managed surgically for the treatment of degenerative spondylolisthesis of the cervical spine.PurposeTo describe the clinical presentation and radiographic findings associated with degenerative cervical spondylolisthesis, and to report the long-term results of surgically managed patients.Study designAnalysis of 58 patients treated with anterior cervical decompression and fusion for degenerative spondylolisthesis of the cervical spine.Patient sampleFrom 1974 to 2003, 58 patients were identified as having degenerative spondylolisthesis of the cervical spine occurring in the absence of trauma, systemic inflammatory arthropathy, or congenital abnormality. These patients were identified from a database of approximately 500 patients with degenerative cervical spine disorders treated by the senior one of us.Outcome measuresPatient outcomes were evaluated with regard to neurologic improvement (Nurick grade myelopathy) and osseous fusion.MethodsThe records of 58 patients were reviewed. The average follow-up period was 6.9 years (range, 2–24 years). Seventy-two cervical levels demonstrated spondylolisthesis. In all cases, there was radiographic evidence of facet degeneration and subluxation. All patients were treated with anterior cervical decompression and arthrodesis with iliac crest structural graft. This most commonly involved corpectomy of the caudal vertebrae. Three patients required additional posterior facet fusion.ResultsFifty-eight patients demonstrated 72 levels of involvement. The C4–C5 level was most frequently involved (43%). Two radiographically distinct types of listhesis were observed based on the amount of disc degeneration and the degree of spondylosis at adjacent levels. The average neurologic improvement was 1.5 Nurick grades. The overall fusion rate was 92%. Three patients were treated with combined anterior-posterior arthrodesis. The prevalence of myelopathy and instability pattern was greater in the listheses occurring adjacent to spondylotic levels.ConclusionsDegenerative spondylolisthesis is relatively common in the cervical spine. Common to all cases is facet arthropathy and neurologic compression. Anterior cervical decompression and arthrodesis appears to yield excellent union rates and neurological improvement in those patients having cervical degenerative spondylolisthesis and significant neurological sequelae who have failed nonoperative treatments.     

Management of degenerative spondylolisthesis: development of appropriate use criteria

BACKGROUND CONTEXTOutcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized.PURPOSEThe purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios.STUDY DESIGNA Modified Delphi process was used.METHODSThe methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 – 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory.RESULTSThere were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.CONCLUSIONSMultidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).     

Etiology-Based Classification of Adjacent Segment Disease Following Lumbar Spine Fusion

Background

Adjacent segment disease (ASDz) is a potential complication following lumbar spinal fusion. A common nomenclature based on etiology and ASDz type does not exist and is needed to assist with clinical prognostication, decision making, and management.

Questions/Purposes

The objective of this study was to develop an etiology-based classification system for ASDz following lumbar fusion.

Methods

We conducted a retrospective chart review of 65 consecutive patients who had undergone both a lumbar fusion performed by a single surgeon and a subsequent procedure for ASDz. We established an etiology-based classification system for lumbar ASDz with the following six categories: “degenerative” (degenerative disc disease or spondylosis), “neurologic” (disc herniation, stenosis), “instability” (spondylolisthesis, rotatory subluxation), “deformity” (scoliosis, kyphosis), “complex” (fracture, infection), or “combined.” Based on this scheme, we determined the rate of ASDz in each etiologic category.

Results

Of the 65 patients, 27 (41.5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as “neurologic.” Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as “degenerative.” Ten patients (15.4%) had spondylolisthesis or instability and were classified as “instability,” and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as “deformity.” Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as “combined.”

Conclusion

This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.

     

Interobserver variance and patient heterogeneity influencing the treatment of grade I spondylolisthesis

BACKGROUND CONTEXTDespite well done randomized clinical trials, the role of fusion as an adjunct to decompression for the treatment of patients with degenerative spondylolisthesis remains controversial. There is substantial variation in the use of fusion as well as the techniques used for fusion for a population of patients all described by a single ICD10 code.PURPOSEWe sought to investigate the source of the variation in the perceived role of fusion by looking at surgeon as well as patient-specific factors.STUDY DESIGNProspective cohort study examining the variability of recommendations from an expert panel of surgeons-based imaging and clinical vignettes.PATIENT SAMPLEPatients with degenerative spondylolisthesis and stenosis.OUTCOME MEASURESA six-category treatment schema based on level of invasiveness of proposed surgeries with one through three representing nonfusion strategies and categories four through six representing fusion strategies.METHODSThe authors are conducting the ongoing spinal laminectomy vs instrumented pedicle screw II study in which patients with grade one degenerative spondylolisthesis and stenosis are randomized to two groups: a review group in which patients are treated as per recommendations of an expert panel and a nonreview group in which patients are treated as per the referring surgeon's preference. In the former (review group), clinical vignettes and radiographic studies were evaluated by an expert panel of spine surgeons. The panel then provided these recommendations to the referring surgeon. We investigated the underlying variability by looking both at the number of similar or different recommendations received by an individual patient (surgeon-related variability) as well as the number of similar or different recommendations offered by individual surgeons across the population of patients (patient heterogeneity). Agreement between surgeons for fusion vs nonfusion (Categories 1–3 vs 4–6) was calculated using a Kappa value from a mixed effects logistic regression model. We looked at Kappa for agreement and weighted Kappa for association of ratings on the ordinal 1 to 6 scale with a mixed effects linear regression model. Additionally, we analyzed the summary of data between patients after averaging the rater scores within patients. Similarly, we summarized the data between surgeons after averaging their scores over the patients that each surgeon reviewed.RESULTSOne hundred and fourteen patients received 1,463 treatment recommendations. On average, fusion was recommended 58.5% of the time. Overall agreement was low, and perfect agreement on the need for fusion was seen in only 24 (21.1%) of patients. Kappa statistic for agreement on fusion was 0.378 (95% confidence interval 0.324–0.432). The average score across surgeons was 4.2 (0.6) with a range of 3 to 5.3. The most common single recommendation was for fusion with interbody fusion (40.8%) and the lowest was for decompression with noninstrumented fusion (0.5%).CONCLUSIONSWe demonstrated variability in surgical approach when individual patients were evaluated by a panel of surgeons indicating that even "expert" surgeons disagree with each other regarding the need for fusion in individual patients. We were also able to demonstrate that individual patients received consistent recommendations that were very different from those received by other individuals evaluated by the same surgeons. This indicates that there is patient-related heterogeneity driving variability independent of surgeon factors.     

Clinical and radiographic assessment of transforaminal lumbar interbody fusion using HEALOS collagen-hydroxyapatite sponge with autologous bone marrow aspirate

Background contextStudies have suggested that the use of bone marrow aspirate (BMA) with HEALOS (DePuy Spine, Raynham, MA), a collagen-hydroxyapatite sponge (CHS), is an effective substitute for autologous iliac crest bone graft when used in fusion procedures of the lumbar spine.PurposeTo assess clinical and radiographic outcomes after implantation of BMA/CHS in patients undergoing transforaminal lumbar interbody fusion (TLIF) with posterolateral fusion (PLF).Study design/settingCase series radiographic outcome study.Patient sampleTwenty patients.Outcome measuresRadiographs/computed tomography (CT) scans.MethodsFrom September 2003 to October 2004, 20 patients (22 interbody levels) were implanted with BMA/CHS via TLIF/PLF with interbody cages and posterior pedicle screws. All patients were retrospectively identified and invited for a 2-year prospective follow-up. Plain radiographs with dynamic films and CT scans were taken, and fusion was assessed in a blinded manner.ResultsFollow-up averaged 27 months (range: 24–29). Primary diagnosis included spondylolisthesis (17 patients), scoliosis with asymmetric collapse (2 patients), and postdiscectomy foraminal stenosis (1 patient). The overall fusion rate was 95% (21/22 levels, 19/20 patients). Anteriorly bridging bone was observed in 91% of the anteriorly fused levels (20/22), of which 65% (13/20) occurred through and around the cage and 35% (7/20) around the cage only. Unilateral or bilateral bridging of the posterior fusion masses was observed in 91% (20/22), with 55% occurring bilaterally (12/22). In 4 (18%) cases, bridging only occurred either posteriorly (2 cases) or anteriorly (2 cases). Complications included one deep wound infection.ConclusionsAt the 2-year follow-up, BMA/CHS showed acceptable fusion rates in patients undergoing TLIF/PLF, and can be considered as an alternative source of graft material.     

Spine Tango annual report 2012

Purpose

Since the Spine Tango registry was founded over a decade ago it has become established internationally. An annual report has been produced using the same format as the SWEspine group to allow for first data comparisons between the two registries.

Methods

Data was captured with the latest generation of surgery and follow-up forms. Also, the Core Outcome Measures Index (COMI) from interventions performed in the year 2012 with follow-up to June 2013 was analyzed. Groups of patients with the most common degenerative lumbar spine diseases and a single group of patients with degenerative cervical spine diseases were created. The demographics, risk factors, previous treatments, current treatment, short-term outcomes, patient satisfaction and complications were analyzed. Pre- and postoperative pain and function scores were derived from the COMI.

Results

About 6,500 procedures were captured with Spine Tango in 2012. The definitions and composition of all the degenerative groups could not completely be matched between the two registries with the consequence that the age and sex distributions were partially different. Preoperative pain levels were similar. The short-term outcomes available did not allow for evaluation of the final result of surgical intervention. This will be possible with the longer term data in the next annual report. There was a distinct disparity in reported complication rates between surgeons and patients.

Conclusions

This is a valuable first step in creating comparable reports for SWEspine and Spine Tango. The German spine registry may be able to collaborate in the future because of similar items and data structure as Spine Tango. There needs to be more work on understanding the harmonization of the different degenerative subgroups. The Spine Tango report is weakened by the short and incomplete follow-up. The visual presentation of data may be a useful model for aiding decision making for surgeons and patients in the future.

     

Should patients with lumbar stenosis and grade I spondylolisthesis be treated differently based on spinopelvic alignment? A retrospective,two-year,propensity matched,comparison of patient-reported outcome measures and clinical outcomes from multiple sites within a single health system

BACKGROUNDDegenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored.PURPOSEThis study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion.STUDY DESIGN/SETTINGRetrospective sub-group analysis of observational, prospectively collected cohort study.PATIENT SAMPLE679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center.OUTCOME MEASURESThe primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition.METHODSRadiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as “high” and “low” mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of “cases” (fusion) and “controls” (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch.RESULTS49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152).CONCLUSIONSLumbar laminectomy with fusion was superior to laminectomy in health–related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.     

Degenerative Spondylolisthesis: Diagnosis and Treatment

Degenerative spondylolisthesis is most often seen at the L4-5 level. The most common complaint is back pain, but the advent of leg symptoms, such as claudication and restless legs syndrome, is often the reason for seeking specialized medical attention. Conservative treatment usually suffices; extended bed rest is of little value. The 15% of patients who are surgical candidates are those with clinical signs and symptoms of cauda equina abnormality, progressive muscular weakness, or progressive incapacitating radicular pain or claudication. The author advocates pedicle-to-pedicle decompression with preservation of the articular facets as the essential operation. The indications for fusion have been debated, but recent prospective studies show improved outcomes after fusion. The risk of significant morbidity associated with laminectomy and fusion increases as a function of age and magnitude of operation; therefore, careful patient selection for surgical intervention is vital.     

Differentiation of pain-related functional limitations in surgical patients with lumbar spinal stenosis (LSS) using the Oswestry Disability Index: a Canadian Spine Outcomes and Research Network (CSORN) study

Background ContextThe Oswestry Disability Index (ODI) is the most commonly used outcome measure of functional outcome in spine surgery. The ability of the ODI to differentiate pain related functional limitation specifically related to degenerative lumbar spinal stenosis (LSS) is unclear.PurposeThe purpose of this study was to determine the ability of the functional subsections of the ODI to differentiate the specific patient limitation(s) from symptomatic LSS and the functional impact of surgery.Study DesignAnalysis of prospectively collected data from the Canadian Spine Outcomes and Research Network (CSORN).Patient sampleA total of 1,497 lumbar spinal stenosis patients with a dominant complaint of neurogenic claudication, radiculopathy or back pain were identified in the CSORN registry.Outcome MeasuresThe ODI questionnaire version 2.0 was assessed as an outcome measure.MethodsThe difference at baseline and the pre-to-post (1-year) surgical change of the ODI individual questions was assessed. Analysis of variance, two-tailed paired sample Student t test were used for statistical analysis. Cohen d was used as an index of effect size, defined as "large" when d ≥0.8.ResultsThe mean age at surgery was 65 (±11) years and (50.8%) of the patients were female. Preoperatively, highest functional limitations were noted for standing, lifting, walking, pain intensity and social life (mean 3.2, 2.9, 2.5, 2.9, 2.5 respectively). At 1-year follow-up, overall there was a significant improvement in all individual questions and the overall ODI (all p<.001), with similar patterns seen for each dominant complaint. The greatest effect of surgery was noted in the walking, social life and standing domains (all d≥0.81), while personal care, sitting and lifting showed the least improvement (all d≤0.51). In subgroup analyses, the overall ODI baseline scores and subsection limitations were statistically significantly higher in females, those without degenerative spondylolisthesis and those undergoing fusion, although these differences were not considered clinically significant. Preoperative differentiation of LSS specific functional limitation and postoperative changes in all subgroups was similar to the overall LSS cohort.ConclusionsThe results of this study support the ability of the ODI to differentiate the self-reported pain related functional effects of neurogenic claudication, radiculopathy or back pain from LSS and changes associated with surgical intervention. Disaggregated use of the ODI could be a simple tool to aid in preoperative education regarding specific areas of pain related dysfunction and potential for improvement with LSS surgery.     

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

BACKGROUND CONTEXTMinimally 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.PURPOSETo determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technologySTUDY DESIGN/SETTINGRetrospective Cohort StudyPATIENT SAMPLEPatients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cageOUTCOME MEASURESPatient-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)METHODSPatients 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.RESULTSA 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).CONCLUSIONSWhile 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.     

微创和开放手术治疗腰椎峡部裂滑脱的疗效分析

目的 比较微创和开放两种术式治疗腰椎峡部裂滑脱的临床效果.方法 采用改良内镜(METRx)减压联合经皮椎弓根螺钉固定(Sextant)微创治疗腰椎峡部裂滑脱25例,传统开放手术治疗31例.统计手术时间、术中失血量、平均住院日、术后镇痛药物使用情况;用VAS评分评估患者术前、术后疼痛缓解情况;采用改良Macnab标准评估临床疗效;影像学观察比较术前、术后椎体滑脱距离、椎间盘高度、滑脱角改善情况及椎问融合率.结果 患者平均随访2.8年(2～4.5年),5例失访.微创组术中失血量、平均住院时间较开放组明显减少;手术时间较开放组长,但无显著性差异.最终随访的VAS评分方面.微创组和开放组均较术前明显降低.具有显著性差异;两组病例在MacNab 临床疗效评价结果 及椎间融合率方面相似,没有显著性差异;两组病例腰椎滑脱距离、椎间盘高度及滑脱角均较术前改善,并有统计学意义,但开放组和微创组比较,无统计学意义.结论 微创手术具有创伤小、术中出血少、术后疼痛轻、平均住院时间短、术后恢复快等特点.而椎问融合率及临床腰部功能评价与开放手术疗效相似,是治疗腰椎峡部裂滑脱的一种有效方法.     

Substantial clinical benefit of minimally invasive lateral interbody fusion for degenerative spondylolisthesis

Purpose

Conventional lumbar arthrodesis for the treatment of degenerative spondylolisthesis (DS) is associated with high complication rates and variable clinical efficacy. Modern minimally invasive (MIS) approaches may reduce the morbidity and produce greater clinical improvement compared to traditional surgical techniques. The objective of this study is to report radiographic outcomes and evaluate clinical improvements in the context of substantial clinical benefit for DS patients treated with a MIS 90° lateral, transpsoas approach for lumbar interbody fusion.

Methods

From 2005 to 2011, 60 consecutive patients were treated with MIS lateral interbody fusion for Grade I or II DS at a single institution. Mean patient age was 68 years, 75 % were female, and 30 % had undergone previous lumbar surgery. A total of 71 levels were treated, supplemental posterior fixation was used in 57 (95 %) cases, and 26 (43 %) patients underwent additional direct posterior decompression.

Results

Average follow-up was 20.3 months. Average ORT, EBL, and LOS were 206 min, 83 cc, and 1.29 days, respectively. Complications occurred in 3 (5 %) patients. Transient approach-related thigh/groin pain was observed in 5 (8 %) cases. There were no cases of pseudoarthrosis. At 1 year, LBP improved 71 %, LP improved 68 %, ODI decreased 52 %, and SF-36 PCS and MCS improved 43 and 21 %, respectively. Substantial clinical benefit was met by 94.7 % of patients on NRS LBP, by 84.6 % on NRS LP, by 83.7 % on ODI, and by 66.7 % on SF-36 PCS. Disc height increased 71 % and segmental lordosis increased 27.8 % at treated levels. Foraminal height, width, and volume increased 19.7, 18.0, and 39.6 %, respectively. Slip improved 60.7 % with interbody fusion only and further improved to 69.2 % after the placement of supplemental instrumentation.

Conclusions

MIS lateral interbody fusion in the treatment of DS resulted in significant improvements in clinical and radiographic outcomes, with a low complication rate and a high proportion of patients achieving substantial clinical benefit.

     

Transforaminale lumbale interkorporelle Fusion zur Versorgung der degenerativen Spondylolisthese

Introduction

Degenerative spondylolisthesis (DS) is a common cause of lumbal and lumbosacral pain as well as radicular pain. Retention and fusion is a good treatment option. Some patients have a symptomatic adjacent degenerative disc disease (DDD) in addition to DS. In these cases the adjacent segments should be fused as well. There are different techniques of fusion available, such as posterior with instrumentation or additional anterior support. This study evaluated results of transforaminal lumbar interbody fusion (TLIF) in patients with monosegmental DS and adjacent DDD.

Material and methods

A total of 28?patients with monosegmental DS and adjacent DDD were included into the study (all patients with bisegmental posterior instrumentation and fusion, 14?patients 1 level TLIF, 14?patients 2 level TLIF). Before surgery and 12?months after surgery the following measurements were made: pain (visual analog scale VAS), Oswestry disability index (ODI) and plain radiographs with radiometric analysis. In a sub-analysis patients with 1 and 2 level TLIF were compared.

Results

Pain reduction (average VAS from 8.7?C3.1) and ODI (63% to 28%) showed significant improvements. Radiometric analysis showed a significant disc height reconstruction and a significant reduction of spondylolisthesis (TLIF level with spondylolisthesis). Bisegmental anterior support showed a significantly better relordosation compared to monosegmental anterior support. The complication rate was 21.4% including hemorrhages, dura leakage, wound infection and adjacent segment degeneration. There were no fatal complications.

Discussion

The TLIF procedure is a safe and effective treatment for monosegmental DS with adjacent symptomatic DDD. Clinical results (pain, function) show no difference between both kinds of fusion (dorsal fusion and instrumentation versus dorsal fusion with instrumentation and TLIF) for the adjacent DDD. However, additional anterior support is more effective for relordosation of the segment. This could have impact on the mid-term and long-term outcome or in cases of adjacent segment fusion.     

Comparison of Lumbosacral Fusion Grade in Patients after Transforaminal and Anterior Lumbar Interbody Fusion with Minimum 2-Year Follow-Up

Objective

Generally, anterior lumbar interbody fusion (ALIF) was believed superior to transforaminal lumbar interbody fusion (TLIF) in induction of fusion. However, many studies have reported comparable results in lumbosacral fusion rate between the two approaches. This study aimed to evaluate the realistic lumbosacral arthrodesis rates following ALIF and TLIF in patients with degenerative spondylolisthesis as measured by CT and radiology.

Methods

Ninety-six patients who underwent single-level L5-S1 fusion through ALIF (n = 48) or TLIF (n = 48) for degenerative spondylolisthesis at the Spine Center, University of California San Francisco, between October 2014 and December 2017 were retrospectively evaluated. Fusion was independently evaluated and categorized as solid fusion, indeterminate fusion, or pseudarthroses by two radiologists using the modified Brantigan–Steffee–Fraser (mBSF) grade. Clinical data on sex, age, body mass index, Meyerding grade, smoking status, follow-up times, complications, and radiological parameters including disc height, disc angle, segmental lordosis, and overall lumbar lordosis were collected. The fusion results and clinical and radiographic data were statistically compared between the ALIF and TLIF groups by using t-test or chi-square test.

Results

The mean follow-up period was 37.5 (ranging from 24 to 51) months. Clear, solid radiographic fusions were higher in the ALIF group compared with the TLIF group at the last follow-up (75% vs 47.9%, p = 0.006). Indeterminate fusion occurred in 20.8% (10/48) of ALIF cases and in 43.8% (21/48) of TLIF cases (p = 0.028). Radiographic pseudarthrosis was not significantly different between the TLIF and ALIF groups (16.7% vs 8.3%; p = 0.677). In subgroup analysis of the patients without bone morphogenetic protein (BMP), the solid radiographic fusion rate was significantly higher in the ALIF group than that in the TLIF group (78.6% vs 45.5%; p = 0.037). There were no differences in sex, age, body mass index, Meyerding grade, smoking status, or follow-up time between the two groups (p > 0.05). The ALIF group had more improvement in disc height (7.8 mm vs 4.7 mm), disc angle (5.2° vs 1.5°), segmental lordosis (7.0° vs 2.5°), and overall lumbar lordosis (4.7° vs 0.7°) compared with the TLIF group (p < 0.05). Overall complication rates were similar between the TLIF and ALIF groups (10.4% vs 8.33%; p > 0.999).

Conclusions

With a minimum 2-year radiographic analysis of arthrodesis at lumbosacral level by radiologists, the rate of solid radiographic fusions was higher in the ALIF group compared with the TLIF group, whereas the TLIF group had a higher rate of indeterminate fusion. Radiographic pseudarthrosis did not differ significantly between the TLIF and ALIF groups.     

Effect of interbody fusion compared with posterolateral fusion on lumbar degenerative spondylolisthesis: a systematic review and meta-analysis

BACKGROUND CONTEXTLumbar degenerative spondylolisthesis is a relatively common pathology, and surgical treatment is an option in selected cases. The common use of anterior column support by interbody fusion (IBF) has not been adequately studied.PURPOSEThe primary objective of this systematic review and meta-analysis was to compare the functional and surgical outcomes after posterolateral fusion (PLF) and IBF for the treatment of degenerative spondylolisthesis.STUDY DESIGNA systematic review and meta-analysis was conducted to identify studies analyzing the effects of IBF compared to those of instrumented PLF on degenerative spondylolisthesis.PATIENT SAMPLEA total of 1,063 patients were included in the analysis. Of them, 470 patients were treated with PLF and 593 with IBF.OUTCOME MEASURESThe outcomes analyzed were the visual analog scale and numerical rating scale scores for back pain, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36) score, 12-Item Short Form Health Survey (physical and mental components) score, blood loss amount, surgical time, hospital stay duration, fusion rate, lumbar lordosis, sacral slope, and postoperative complications.METHODSA search was conducted using the MEDLINE, Cochrane, and Google Scholar databases for studies published between January 1985 and February 2021. Both retrospective and prospective studies that compared between IBF and PLF were included.RESULTSA total of 2,819 articles were screened, and 38 full-text articles were selected for a detailed investigation, of which 12 articles were found to match all the inclusion criteria and were included in the meta-analysis. There was an improvement in the sacral slope (mean difference [MD] = 3 [95% confidence interval {CI} = 0.83–5.17]) and fusion rate (odds ratio [OR] = 0.47 [95% CI = 0.26–0.86]) in the IBF group. The incidence of neural injury was higher in the IBF group (OR = 0.28 [95% CI = 0.13–0.60]) than in the PLF group. There were no differences in the back pain scores, ODI, SF-36 score, blood loss amount, surgical time, hospital stay duration, lumbar lordosis, infection, and durotomy between the groups.CONCLUSIONSIBF for the treatment of lumbar degenerative spondylolisthesis showed better results in terms of the fusion rate and sacral slope, but which did not translate into better clinical outcomes. Further randomized and prospective studies are necessary to elucidate the optimal therapeutic options.     

Characteristics and outcomes of patients undergoing lumbar spine surgery for axial back pain in the Michigan Spine Surgery Improvement Collaborative

BACKGROUND CONTEXTThe 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.PURPOSETo determine the outcome of surgery (decompression only vs. fusion) for pure axial back pain without leg pain.STUDY DESIGN/SETTINGProspectively collected data in the Michigan Spine Surgery Improvement Collaborative (MSSIC).PATIENT SAMPLEPatients 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 MEASURESMinimally 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.METHODSLog-Poisson generalized estimating equation models were constructed with patient-reported outcomes as the independent variable, reporting adjusted risk ratios (RR_adj).RESULTSOf 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% (RR_adj=0.85, p=.038). For every one-unit increase in preoperative back pain, the likelihood for a favorable outcome increased by 8% (RR_adj=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% (RR_adj=0.84, p=.041). The probability of obtaining a MCID in back pain increased by 9% (RR_adj=1.09, p<.001) for every 1-unit increase in baseline back pain score and by 14% for fusions versus decompression alone (RR_adj=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 (RR_adj=0.70, p<.001) and increased by 8% with every one-unit increase in baseline back pain score (RR_adj=1.08, p<.001).CONCLUSIONSOnly 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.     

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

Purpose

Symptomatic lumbar spinal stenosis can be treated with decompression surgery. A recent review reported that, after decompression surgery, 1.6–32.0% of patients develop postoperative symptomatic spondylolisthesis and may therefore be indicated for lumbar fusion surgery. The latter can be more challenging due to the altered anatomy and scar tissue. It remains unclear why some patients get recurrent neurological complaints due to postoperative symptomatic spondylolisthesis, though some associations have been suggested. This study explores the association between key demographic, biological and radiological factors and postoperative symptomatic spondylolisthesis after lumbar decompression.

Methods

This retrospective cohort study included patients who had undergone lumbar spinal decompression surgery between January 2014 and December 2016 at one of two Spine Centres in the Netherlands or Switzerland and had a follow-up of two years. Patient characteristics, details of the surgical procedure and recurrent neurological complaints were retrieved from patient files. Preoperative MRI scans and conventional radiograms (CRs) of the lumbar spine were evaluated for multiple morphological characteristics. Postoperative spondylolisthesis was evaluated on postoperative MRI scans. For variables assessed on a whole patient basis, patients with and without postoperative symptomatic spondylolisthesis were compared. For variables assessed on the basis of the operated segment(s), surgical levels that did or did not develop postoperative spondylolisthesis were compared. Univariable and multivariable logistic regression analyses were used to identify associations with postoperative symptomatic spondylolisthesis.

Results

Seven hundred and sixteen patients with 1094 surgical levels were included in the analyses. (In total, 300 patients had undergone multilevel surgery.) ICCs for intraobserver and interobserver reliability of CR and MRI variables ranged between 0.81 and 0.99 and 0.67 and 0.97, respectively. In total, 66 of 716 included patients suffered from postoperative symptomatic spondylolisthesis (9.2%). Multivariable regression analyses of patient-basis variables showed that being female [odds ratio (OR) 1.2, 95%CI 1.07–3.09] was associated with postoperative symptomatic spondylolisthesis. Higher BMI (OR 0.93, 95%CI 0.88–0.99) was associated with a lower probability of having postoperative symptomatic spondylolisthesis.

Multivariable regression analyses of surgical level-basis variables showed that levels with preoperative spondylolisthesis (OR 17.30, 95%CI 10.27–29.07) and the level of surgery, most importantly level L4L5 compared with levels L1L3 (OR 2.80, 95%CI 0.78–10.08), were associated with postoperative symptomatic spondylolisthesis; greater facet joint angles (i.e. less sagittal-oriented facets) were associated with a lower probability of postoperative symptomatic spondylolisthesis (OR 0.97, 95%CI 0.95–0.99).

Conclusion

Being female was associated with a higher probability of having postoperative symptomatic spondylolisthesis, while having a higher BMI was associated with a lower probability. When looking at factors related to postoperative symptomatic spondylolisthesis at the surgical level, preoperative spondylolisthesis, more sagittal orientated facet angles and surgical level (most significantly level L4L5 compared to levels L1L3) showed significant associations. These associations could be used as a basis for devising patient selection criteria, stratifying patients or performing subgroup analyses in future studies regarding decompression surgery with or without fusion.