Comparison of interventions for lumbar disc herniation: a systematic review with network meta-analysis

BackgroundImplants for use in disc herniation surgery have been commercially available for some time. Several clinical trials have shown promising results. There are now a wide variety of surgical methods for treating lumbar disc herniation.PurposeThe objective of this systematic review was to compare all current surgical methods for disc herniation, including newer methods with implants for annulus repair and dynamic stabilization.Study designSystematic review and network meta-analysis.MethodsPRISMA-P guidelines were followed in this review. Literature search in PubMed, Embase, and Cochrane library databases identified eligible randomized controlled trials (RCT) studies comparing interventions for lumbar disc surgery. The investigated outcomes were: changes in pain score, disability score and reoperation rate with a minimum follow-up of 1 year. Risk of bias was assessed in concordance with Cochrane Neck and Back Review Group recommendation. A network meta-analysis was performed using gemtc and BUGSnet software, and each outcome evaluated using Confidence in Network Meta-Analysis (CINeMA).ResultsThirty-two RCT studies, with 4,877 participants, and eight different interventions were identified. A significant difference was seen in change of pain score, as all treatments were superior to conservative treatment and percutaneous discectomy. This difference was only found to be of clinically importance when comparing conservative treatment and dynamic stabilization. There was no significant difference in reoperation rates or change in disability score, regardless of treatment. However, SUCRA plots showed a trend in ranking annulus repair and dynamic stabilization highest. Risk of bias assessment showed that 15 studies had a high overall risk of bias. Meta-regression with risk of bias as covariate did not indicate any influence in risk of bias on the model. Confidence in Network Meta-Analysis evaluation showed a high level of confidence for all treatment comparisons.ConclusionsWith this network meta-analysis, we have aimed to compare all treatments for herniated lumbar disc in one large comprehensive systematic review and network meta-analysis. We have compared across the three main outcomes: disability score, pain score and reoperation rate. We were not able to rank one single treatment as the best. Most of the treatment performed at the same level. However percutaneous discectomy and conservative treatment consistently performed worse than the other treatments. In general, the CINeMA evaluation according to the GRADE recommendations gave a high level of confidence for the study comparisons.     

Mental health improvements after elective spine surgery: a Canadian Spine Outcome Research Network (CSORN) study

BACKGROUND CONTEXTSpine 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.PURPOSEDetermination whether improvements in health-related quality of life (HRQOL) resulting from successful spine surgery leads to improvements in mental health.STUDY DESIGN/SETTINGThe Canadian Spine Outcome Research Network prospective surgical outcome registry.OUTCOME MEASURESChange 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.METHODSThe 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.RESULTSEighteen 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.CONCLUSIONSLarge 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.     

Modified-frailty index does not independently predict complications,hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis

BACKGROUND CONTEXTFrailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis.PURPOSEThe aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis.STUDY DESIGNA retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016.PATIENT SAMPLEAll adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as “not frail”, 1 as “mild” frailty, and 2 or greater as “moderate to severe” frailty.OUTCOME MEASURESPatient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed.METHODSA multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission.RESULTSThere were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days, p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%, p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%, p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%, p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378).CONCLUSIONSOur study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.     

Comparison of 3D-printed titanium-alloy,standard titanium-alloy,and PEEK interbody spacers in an ovine model

BACKGROUND CONTEXTOsseointegration is a pivotal process in achieving a rigid fusion and ultimately a successful clinical outcome following interbody fusion surgery. Advancements in 3D printing technology permit commonly used titanium interbody spacers to be designed with unique architectures, such as a highly interconnected and specific porous structure that mimics the architecture of trabecular bone. Interbody implants with a microscale surface roughness and biomimetic porosity may improve bony ongrowth and ingrowth compared to traditional materials.PURPOSEThe purpose of this study was to compare the osseointegration of lumbar interbody fusion devices composed of surgical-grade polyetheretherketone (PEEK), titanium-alloy (TAV), and 3D-printed porous, biomimetic TAV (3DP) using an in vivo ovine model.STUDY DESIGNIn Vivo Preclinical Animal StudyMETHODSEighteen sheep underwent two-level lateral lumbar interbody fusion randomized with either 3DP, PEEK, or TAV interbody spacers (n=6 levels for each spacer per time point). Postoperative time points were 6 and 12 weeks. Microcomputed tomography and histomorphometry were used to quantify bone volume (BV) within the spacers (ingrowth) and the surface bone apposition ratio (BAR) (ongrowth), respectively.RESULTSThe 3DP-treatment group demonstrated significantly higher BV than the PEEK and TAV groups at 6 weeks (77.3±44.1 mm³, 116.9±43.0 mm³, and 108.7±15.2 mm³, respectively) (p<.05). At 12 weeks, there were no BV differences between groups (p>.05). BV increased in all groups from the 6- to 12-week time points (p<.05). At both time points, the 3DP-treated group (6w: 23.6±10.9%; 12w: 36.5±10.9%) had significantly greater BAR than the PEEK (6w: 8.6±2.1%; 12w: 14.0±5.0%) and TAV (6w: 6.0±5.7%; 12w: 4.1±3.3%) groups (p<.05).CONCLUSIONS3DP interbody spacers facilitated greater total bony ingrowth at 6 weeks, and greater bony ongrowth postoperatively at both 6 and 12 weeks, in comparison to solid PEEK and TAV implants.CLINICAL SIGNIFICANCEBased on these findings, the 3DP spacers may be a reasonable alternative to traditional PEEK and TAV spacers in various clinical applications of interbody fusion.     

Outcomes of the use of cement-augmented cannulated pedicle screws in lumbar spinal fusion

BACKGROUND CONTEXTThere are few studies of the radio-clinical outcomes of cement-augmented cannulated pedicle screw (CPS) fixation in osteoporotic patients.PURPOSETo compare the radiological and clinical outcomes between groups receiving cement-augmented CPS and solid pedicle screws (SPS) in lumbar fusion surgery.STUDY DESIGN/SETTINGRetrospective comparative studyPATIENT SAMPLEA total of 187 patients who underwent lumbar fusion surgery for degenerative spinal stenosis or spondylolisthesis from 2014 to 2019.OUTCOME MEASURESRadiological 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.METHODSOutcomes 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.RESULTS324 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.CONCLUSIONIn 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 EVIDENCELevel 4     

3D打印导航模板辅助椎弓根螺钉在脊柱侧弯矫形术中的置钉效果

目的:探讨3D打印导航模板辅助椎弓根螺钉在脊柱侧弯矫形术中的置钉效果。方法:回顾性分析2018年1月至2020年6月间采用椎弓根螺钉置钉法治疗的39例脊柱侧弯患者的病例资料,其中采用3D打印导航模板辅助置钉(3D组)18例,常规徒手置钉方法置钉(徒手组)21例。记录并比较2组的置钉时间、置钉出血量、置钉透视次数、置钉等级及准确率、置钉可接受率、置钉并发症和主弯矫形率。采用SPSS 19.0软件进行统计学分析。结果:39例患者均顺利完成术中置钉,术后徒手组4例出现并发症,治疗后症状消失,3D组无相关并发症出现。3D组的置钉时间、置钉出血量、置钉透视次数少于徒手组,置钉等级及准确率、置钉可接受率均优于徒手组,差异有统计学意义(P<0.05);3D组和徒手组主弯矫形率比较差异无统计学意义(P>0.05)。结论:在脊柱侧弯矫形术中采用3D打印导航模板辅助椎弓根螺钉置钉,可显著降低置钉难度、优化术中置钉操作、提升置钉效果,是一种较好的置钉方法。     

The predictive significance of bone mineral density on postoperative pain relief in knee osteoarthritis patients after total knee arthroplasty: A prediction model

BackgroundBone mineral density (BMD) may be an important factor affecting the clinical outcomes after total knee arthroplasty (TKA). However, further information regarding BMD in postoperative pain relief is not present yet. This study aims to gain further insight into the predictive significance of BMD in postoperative pain relief in knee osteoarthritis (KOA) patients after TKA.Methods156 KOA patients treated by TKA were included in this study. Visual analogue scale (VAS) was used to measure the pain intensity in patients within one year after TKA. The patients were divided into good pain relief group (the improvement of VAS ≥ 3) and poor pain relief group (the improvement of VAS < 3). BMD and other clinical characteristics were also collected. Logistic regression analysis and receiver operating characteristic curve (ROC curve) were used to evaluate the predictive significance of BMD. Subgroup analysis was used to compare the difference of postoperative pain between High BMD group and Low BMD group extra.Results34 (21.8%) patients had poor pain relief after TKA. Logistic regression analysis indicated that age, BMD, preoperative hospital for special surgery (HSS) scores, preoperative VAS score and postoperative posterior slope angles (PSA) were the risk factors of poor pain relief (P < 0.05). Using BMD as a predictor, the optimum cut-off value of poor pain relief was T-level = ?3.0 SD in the ROC curve, where sensitivity and specificity were 73.5% and 83.7%, respectively. Based on this cut-off value, obvious pain relief was observed in the High BMD group compared with Low BMD group from the 6th month after TKA in the subgroup analysis (P < 0.05).ConclusionsBMD is an effective predictor for postoperative pain relief in KOA patients after TKA, and the poor pain relief should be fully considered especially when BMD T-level ≤ ?3.0 SD.