Impact of instrumentation in lumbar spinal fusion in elderly patients

Background and purpose An increasing number of lumbar fusions are performed using allograft to avoid donor-site pain. In elderly patients, fusion potential is reduced and the patient may need supplementary stability to achieve a solid fusion if allograft is used. We investigated the effect of instrumentation in lumbar spinal fusion performed with fresh frozen allograft in elderly patients.Methods 94 patients, mean age 70 (60–88) years, who underwent posterolateral spinal fusion either non-instrumented (51 patients) or instrumented (43 patients) were followed for 2–7 years. Functional outcome was assessed with the Dallas pain questionnaire (DPQ), the low back pain rating scale pain index (LBPRS), and SF-36. Fusion was assessed using plain radiographs.Results Instrumented patients had statistically significantly better outcome scores in 6 of 7 parameters. Fusion rate was higher in the instrumented group (81% vs. 68%, p = 0.1). Solid fusion was associated with a better functional outcome at follow-up (significant in 2 of 7 parameters). 15 patients (6 in the non-instrumented group and 9 in the instrumented group) had repeated lumbar surgery after their initial fusion procedure. Functional outcome was poorer in the group with additional spine surgeries (significant in 4 of 7 parameters).Interpretation Superior outcomes after lumbar spinal fusion in elderly patients can be achieved by use of instrumentation in selected patients. Outcome was better in patients in which a solid fusion was obtained. Instrumentation was associated with a larger number of additional surgeries, which resulted in a lesser degree of improvement. Instrumentation should not be discarded just because of the age of the patient.     

Lumbar spine instrumented fusion surgery under spinal anaesthesia versus general anaesthesia-A retrospective study of 239 cases

ObjectiveConventionally spinal surgeries are done under general anaesthesia (GA). Plenty of literature is available on lumbar spine non-instrumented surgeries under spinal anaesthesia (SA) but handful of literature is there on lumbar spinal instrumented fusion surgeries under SA. We retrospectively analysed the data of 131 patients operated under SA and 108 patients under GA. Aim of the study was to evaluate the safety, advantages and disadvantages of doing lumbar spine instrumented fusion surgeries under SA.In time of COVID-19 pandemic, aerosol generating procedure like intubation, can be avoided if lumbar spine instrumented fusion surgeries are performed under SA.Methods239 patients aged between 20 and 79 years operated from January 2014 to December 2019 were included in this study. Indications for surgery were lumbar canal stenosis, degenerative or lytic spondylolisthesis. They underwent L4-L5 or L5-S1 fusion surgeries either TLIF or pedicle screw fixation postero lateral fusion (PLF) and decompression. Out of 239 patients,131 were operated under SA and 108 patients under GA. Heart rate, mean arterial pressure (MAP), blood loss, operating room time, post-op pain relief and need of analgesics, cost of surgery and anaesthesia related complications were analysed.ResultsThe study found significantly less blood loss (p<.05), less OR time, better post-op analgesia and lesser incidence of nausea and vomiting in SA (8.4%) than GA (29.6%). We observed average 10% cost reduction in SA. This study did not find any prone position related complication in regional anaesthesia but one transient brachial plexus palsy and one post-op shoulder pain in GA group.ConclusionSA is a safe alternative to GA for lumbar spine instrumented fusion surgery with significant less blood loss, OR time, better post-op analgesia, average 10% overall cost reduction and no reported prone-position related complications.     

The positive effect of posterolateral lumbar spinal fusion is preserved at long-term follow-up: a RCT with 11–13 year follow-up

Introduction Few studies have investigated the long-term effect of posterolateral lumbar spinal fusion on functional outcome. Aim To investigate the long-term result after posterolateral lumbar spinal fusion with and without pedicle screw instrumentation. Methods Questionnaire survey of 129 patients originally randomised to posterolateral lumbar spinal fusion with or without pedicle screw instrumentation. Follow-up included Dallas Pain Questionnaire (DPQ), Oswestry Disability Index (ODI), SF-36 and a question regarding willingness to undergo the procedure again knowing the result as global outcome parameter. Results Follow-up was 83% of the original study population (107 patients). Average follow-up time was 12 years (range 11–13 years). DPQ-scores were significantly lower than preoperatively in both groups (P < 0.005) and no drift towards the preoperative level was seen. No difference between the two groups were observed (instrumented vs. non-instrumented): DPQ Daily Activity mean 37.0 versus 32.0, ODI mean 33.4 versus 30.6, SF-36 PCS mean 38.8 versus 39.8, SF-36 MCS mean 49.0 versus 53.3. About 71% in both groups were answered positively to the global outcome question. Patients who had retired due to low back pain had poorer outcome than patients retired for other reasons, best outcome was seen in patients still at work (P = 0.01 or less in all questionnaires, except SF-36 MCS P = 0.08). Discussion Improvement in functional outcome is preserved for 10 or more years after posterolateral lumbar spinal fusion. No difference between instrumented fusion and non-instrumented fusion was observed. Patients who have to retired due to low back pain have the smallest improvement.     

The comparison of instrumented and non-instrumented fusion in the treatment of lumbar spondylolisthesis: a meta-analysis

Purpose

This meta-analysis compared whether fusion with or without instrumentation to treat this disease differed with respect to patient-centered outcomes.

Methods

Medline, Cochrane, EMBASE, Google Scholar data bases were searched for randomized control trials that investigated patients with severe chronic lower back pain resulting from localized lumbar or lumbosacral instability caused by either isthmic spondylolisthesis or degenerative spondylolisthesis. Included randomized studies reported quantitative outcomes for low back pain and functional recovery. The primary outcome was the improvement of function and the secondary outcomes were the improvement of pain, patients’ satisfactory level, and the fusion rate.

Results

A significantly lower function change in patients with instrumented compared with non-instrumented from baseline (pooled standardized mean difference; ?1.02 (95 % CI ?1.76 to ?0.27); Z ?2.67; (P = 0.008)]. There was no significant pain change for patients with instrumented compared with that of non-instrumented from baseline [pooled standardized mean difference; ?0.07 (95 % CI ?1.25 to 1.12); Z ?0.11; (P = 0.913)]. There was no significant difference in satisfactory level for patients with instrumented compared with that of non-instrumented [pooled OR; 2.36 (95 % CI 0.91–6.11); Z 1.76; (P = 0.078)]. There was significantly higher fusion rate for patients with instrumented compared with that of non-instrumented [pooled OR; 3.28 (95 % CI 2.22–4.85); Z 5.96; (P < 0.001)].

Conclusions

This meta-analysis found that inclusion of fusion surgery with instrumentation provided no benefit as evaluated by patient-reported outcomes in patients with lumbar spondylolisthesis.

Level of evidence

Not applicable.     

Sex life and sexual function in men and women before and after total disc replacement compared with posterior lumbar fusion

Background contextSex life and sexual function may be affected by low back pain (LBP). Sexual dysfunction after anterior lumbar fusion is reported in both men and women, but focus is mainly on impaired male biological function (retrograde ejaculation) as this may cause infertility. This has led to concern as to whether anterior surgery should be employed in men, at least in younger age groups.PurposeTo investigate how chronic low back pain (CLBP) of assumed discogenic origin affects sex life and sexual function in patients considered for surgical treatment, whether this is affected by surgical treatment (total disc replacement [TDR] or posterolateral fusion [PLF]/posterior lumbar interbody fusion [PLIF]), and if so, are there differences between the surgical procedures undertaken.Study designA randomized controlled trial comparing TDR and instrumented lumbar spine fusion, performed either as a PLF or PLIF.Patient sampleOne hundred fifty-two patients were included in this randomized controlled trial to compare the effect on CLBP of either TDR via an anterior retroperitoneal approach or instrumented posterior lumbar fusion, PLF or PLIF.Outcome measuresGlobal assessment of back pain, back pain (visual analog scale [VAS] 0-100), function (Oswestry Disability Index [ODI] 0–100), quality of life (EQ5D [EuroQol] 0–1), and answers on specific sexual function.MethodsOutcome was assessed using data from the Swedish Spine Register (SweSpine). In ODI, one question, ODI 8, reflects the impact of back pain on sex life. This question was analyzed separately. Patients also answered a gender-specific questionnaire preoperatively and at the 2-year follow-up to determine any sexual dysfunction regarding erection, orgasm, and ejaculation. Follow-up was at 1 and 2 years.ResultsBefore surgery, 34% reported that their sex life caused some extra LBP, and an additional 30% that their sex life was severely restricted by LBP. After surgery, sex life improved in both groups, with a strong correlation to a reduction of LBP. The gender-specific questionnaire used to measure sexual function after 2 years revealed no negative effect of TDR or Fusion in men regarding erection or retrograde ejaculation. However, 26% of all men in the Fusion group, compared with 3% in the TDR group, reported postoperative deterioration in the ability to achieve orgasm, despite a reduction of LBP.ConclusionsImpairment of sex life appears to be related to CLBP. An improvement in sex life after TDR or lumbar fusion was positively correlated to a reduction in LBP. Total disc replacement in this study, performed through an anterior retroperitoneal approach, was not associated with greater sexual dysfunction compared with instrumented lumbar fusion performed either as a PLF or as a PLIF. Sexual function, expressed as orgasm, deteriorated in men in the Fusion group postoperatively, in spite of this group reporting less LBP after 2 years.     

Isolated tuberculosis of the lumbar apophyseal joint

Background contextPosterior element tuberculosis is rare accounting for only 3% to 5% of all spinal tuberculosis. To our knowledge, no case of isolated facet joint tuberculosis with coronal decompensation has been reported in literature so far.PurposeThe purpose of this study was to describe a case of tuberculous arthritis of the lumbar facet joint and its effect on coronal balance of the spine.Study designThe study design was a case report.MethodsA 14-year-old boy presented with a 3-month history of back pain without radiation and with normal neurological findings. Computed tomography and magnetic resonance imaging showed destruction of the right L4–L5 facet joint with L5–S1 spondylolytic listhesis. Despite 2 months of antitubercular medication after a core biopsy confirmation of L4–L5 facet tuberculosis, there was progression of coronal decompensation of the spine with severe pain. Instrumentation with intertransverse fusion was done as a secondary procedure.ResultsThe patient was completely relieved of symptoms after instrumented fusion along with antitubercular medication.ConclusionIsolated lumbar facet joint tuberculosis is a rare entity with a potential for coronal decompensation of the spine, which makes early instrumented fusion with antitubercular medication a viable treatment modality.     

Prospective,randomized, double-blinded clinical trial comparing PEEK and allograft spacers in patients undergoing transforaminal lumbar interbody fusion surgeries

BACKGROUND CONTEXTAllograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date.PURPOSEThe study's primary objective was to prospectively investigate clinical and radiological outcomes in patients undergoing lumbar interbody fusions and randomized to receive either PEEK or structural bone allografts.STUDY DESIGN/ SETTINGA prospective, randomized, double-blinded clinical trial was initiated at a single center.PATIENT SAMPLEA total of 138 patients were enrolled, randomized and 121 patients completed the study.OUTCOME MEASURESThe primary clinical outcome parameters were scored from standardized patient-reported questionnaires. The severity of lower back and leg pain was evaluated using the 11-point Visual Analog Scale (VAS). The Oswestry Disability Questionnaire was used to evaluate chronic disability and activities of daily living. Health-related quality of life and functional outcomes were assessed using Health-related Quality of Life Questionnaire (SF-36 v2). Two scores within the scoring algorithm were analyzed: Physical Component (PCS) and Mental Component Summary (MCS). The primary radiological outcomes included restoration and maintenance of vertebral body height, lumbar sagittal and segmental alignment, and fusion status.METHODSAll patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment.RESULTSA total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p<.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively.CONCLUSIONSAlthough allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.     

Two-year fusion and clinical outcomes in 224 patients treated with a single-level instrumented posterolateral fusion with iliac crest bone graft

Background contextReported fusion rates for spine fusions using iliac crest bone graft (ICBG) vary between 40% and 100% because of different fusion techniques, patient comorbidity, diagnosis and assessment criteria.PurposeWe report two-year results of single-level instrumented posterolateral fusions evaluated with radiographs, fine-cut computed tomography (CT) scans with reconstructions and outcome measures.Study design/ settingRetrospective analysis of data from a prospective multicenter randomized clinical controlled trial.Patient samplePatients with various degenerative diagnoses enrolled in the control arm of a Food and Drug Administration (FDA)-regulated, multicenter trial of single-level decompression and posterolateral fusion for degenerative lumbar disease.Outcome measuresShort Form-36 (SF-36), Oswestry Disability Index (ODI), Numeric Rating Scales (0–20) for back, leg, and graft site pain, CT scans, anteroposterior and lateral flexion/extension radiographs.MethodsPatients enrolled in an FDA-regulated, multicenter trial at 29 sites with degenerative lumbar disease treated with single-level instrumented posterolateral fusion with ICBG were included in the analysis. Demographic and surgical data were collected. Clinical outcomes were followed using standard metrics. Fusion was assessed by independent radiologists at 6, 12, and 24 months postoperatively. Two fusion criteria were compared: anteroposterior and flexion/extension radiographs to assess motion and bridging bone, with CT scans as needed to confirm bridging bone; and CT scan assessment for bridging bone only.ResultsOne hundred ninety-four of 224 subjects (86.6%) completed the study. The mean operative time was 2.9 hours with a blood loss of 448.6 mL. The average graft volume was 36.3 mL. There were 21 (9.4%) wound infections, 18 (8.0%) incidental durotomies, 3 (1.3%) implant displacements, 2 (0.9%) malpositioned implants, and 17 (7.6%) graft-related complications. Twenty-seven patients (13.9%) required reoperation, the majority for nonunions. Fusion rates based on radiographs with selective CTs at 6, 12, and 24 months were 65.3%, 82.5%, and 89.3%, respectively. Fusion rates based on bridging bone on CT scans were 56.1%, 71.5%, 83.9%, respectively. Two-year improvement for all outcome measures was significant (p<.001)—ODI 25.3, SF-36 Physical Component Score (PCS) 12.2, back pain 7.9, and leg pain 7.1. Two years postoperatively, 60% of patients complained of graft site pain (mean pain score=8.5).ConclusionIn a large series of patients who had primary single-level instrumented posterolateral fusion with ICBG, evidence of bridging bone on fine-cut CT scans improved with time to 83.9% at 24 months. Significant improvement from baseline was noted in all clinical outcome measures at all time intervals with 75% achieving minimum clinically important difference (MCID) for ODI and 66% achieving MCID for SF-36 PCS.     

Randomized double blind clinical trial of ABM/P-15 versus allograft in noninstrumented lumbar fusion surgery

BACKGROUND CONTEXTDue 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.PURPOSETo evaluate patient reported outcomes (PROs) and the intertransverse fusion rate in noninstrumented posterolateral fusion with either ABM/P-15 or allograft.STUDY DESIGNDouble-blind randomized clinical trial.PATIENT SAMPLEPatients 60 years or older with degenerative spondylolisthesis undergoing decompression and noninstrumented posterolateral fusion.OUTCOME MEASURESVisual analog scales for back and leg pain, Oswestry Disability Index and EuroQoL-5D.METHODSOne 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.”RESULTSThere 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.CONCLUSIONSPatients 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.     

Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator's perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and (b) anterior support. The costs of non-instrumented posterolateral spinal fusion were estimated at DKK 88,285(95% CI 81,369;95,546), instrumented posterolateral spinal fusion at DKK 94,396(95% CI 89,865;99,574) and instrumented posterolateral lumbar spinal fusion + anterior intervertebral support at DKK 120,759(95% CI 111,981;133,738). The net-benefit of the regimens was significantly affected by smoking and functional disability in psychosocial life areas. Multi-level fusion and surgical technique significantly affected the net-benefit as well. Surprisingly, no correlation was found between treatment costs and treatment effects. Incremental analysis suggested that the probability of posterior instrumentation being cost-effective was limited, whereas the probability of anterior intervertebral support being cost-effective escalates as willingness-to-pay per effect unit increases. This study reveals useful and hitherto unknown information both about cost-patterns at the patient-level and determinants of cost-effectiveness. The overall conclusion of the present investigation is a recommendation to focus further on determinants of cost-effectiveness. For example, patient characteristics that are modifiable at a relatively low expense may have greater influence on cost-effectiveness than the surgical technique itself--at least from an administrator's perspective.     

Single-level instrumented posterolateral fusion versus non-instrumented anterior interbody fusion for lumbar spondylolisthesis: a prospective study with a 2-year follow-up

BackgroundSurgery for lumbar spondylolisthesis is widely performed. However, there have been no reports comparing posterolateral and anterior interbody fusion prospectively. We compared instrumented posterolateral fusion with anterior interbody fusion for L4 spondylolisthesis in a prospective study.MethodsForty-six patients diagnosed with L4 degenerated spondylolisthesis were divided into two groups. Twenty-two consecutive patients underwent non-instrumented anterior interbody fusion using an iliac bone graft (ALIF; L4-L5 level), and 24 consecutive patients underwent instrumented posterolateral fusion with local bone (PLF; L4-L5 level). The rates of bone union, visual analog scale (VAS) score, Japanese Orthopedic Association (JOA) score, Oswestry Disability Index (ODI), surgical invasion, and complications were evaluated before and 2 years after surgery.ResultsAge, VAS score, JOA score, and ODI were not significantly different between the two groups before surgery (P > 0.05). Success of bone union between the two groups was not significantly different (P > 0.05). Blood loss during surgery was significantly less; however, periods of bed rest and hospital stay were significantly longer in the ALIF group (P < 0.05). Overall patient satisfaction, and low back and leg pain in both groups were significantly improved after surgery; however, low back pain showed greater improvement in the ALIF group compared with the PLF group (P < 0.05). Complications such as donor site pain (4 patients in the ALIF group) and dural tearing (3 patients in the PLF group) were observed.ConclusionsIf single level fusion for L4 spondylolisthesis is performed, both anterior and posterior methods reduce patients' low back and leg pain. Improvement of low back pain was significantly greater after ALIF; however, periods of hospital stay and of bed rest were significantly longer.     

The influence of lumbar lordosis on spinal fusion and functional outcome after posterolateral spinal fusion with and without pedicle screw instrumentation

The aim of the current study was to examine the correlation between lumbar lordosis, spinal fusion, and functional outcome in patients suffering from severe low back pain, treated by posterolateral spinal fusion with or without pedicle screw instrumentation. One hundred thirty patients were randomly allocated to posterolateral lumbar fusion with or without Cotrel-Dubousset instrumentation. Functional outcome was assessed preoperatively, and 1 and 2 years postoperatively. Lordosis angles of the lumbar spine and fusion rates were assessed at the 1- and 2-year follow-up. No difference in lordosis angle was found between the two groups at any time. Lordosis was unchanged at 2 years compared with preoperative status in both groups. In the instrumented group, nonunion (23%) was followed by a decrease in lordosis at follow-up (p < 0.05). However, in the noninstrumented group, nonunion (14%) resulted in increased lordosis (p < 0.05). No correlation was found between functional outcome and lordosis angle. The current study showed no correlation between functional outcome and lordosis angle either before or after posterolateral spinal fusion. Use of instrumentation did not influence lumbar spinal alignment compared with noninstrumented fusions. The sagittal alignment was stable both 1 and 2 years after solid fusion. The failure mode of instrumented fusions was a reduced degree of lordosis in contrast to an increased degree of lordosis in patients with noninstrumented fusion.     

Allograft alone versus allograft with bone marrow concentrate for the healing of the instrumented posterolateral lumbar fusion

Background contextSpondylodesis in the operative management of lumbar spine diseases has been the subject of numerous studies over several decades. The posterolateral fusion (PLF) with pedicle screw fixation is a commonly used procedure.PurposeTo determine whether the addition of bone marrow concentrate (BMC) to allograft bone increases fusion rate after instrumented posterior lumbar fusion.Study designThe study was prospective, randomized, controlled, and blinded.MethodsEighty patients with degenerative disease of the lumbar spine underwent instrumented lumbar or lumbosacral PLF (22 men, 58 women; body mass index less than 35 for a good visualization of the PLF in the X-rays). In 40 cases, the PLF was done with spongious allograft chips alone (Group I, age 62.7 years in average, range 47–77 years, level of fusion 1–2). In another 40 cases, spongious allograft chips were mixed with BMC (Group II, age 58.5 years in average, range 42–80, level of fusion 1–3), including the mesenchymal stem cells (MSCs). Patients were scheduled for anteroposterior and lateral radiographs 12 and 24 months after the surgery and for computed tomography scanning 24 months after the surgery. Fusion status and the degree of mineralization of the fusion mass were evaluated separately by two radiologists blinded to patient group affiliation. The bony mass was judged as fused if there was uninterrupted bridging of well-mineralized bone between the transverse processes or sacrum, with trabeculation indicating bone maturation on least at one side of the spines.ResultsIn Group I at 12 months, the bone graft mass was assessed in X-rays as fused in no cases (0%) and at 24 months in four cases (10%). In Group II, 6 cases (15%) achieved fusion at 12 months and 14 cases (35%) at 24 months. The statistically significant difference between both groups was proven for complete fusion at both 12 (p=.041) and 24 months (p=.011). Computed tomography scans showed that 16 cases (40%) in Group I and 32 cases (80%) in Group II had evidence of at least unilateral continuous bridging bone between neighboring vertebrae at 24 months (p<.05).ConclusionsWe have confirmed the hypothesis that the autologous BMC together with the allograft is a better alternative for PLF than the allograft alone. The use of autologous MSCs in form of BMC in combination with allograft is an effective option to enhance the PLF healing.     

颈前路短节段自体骨融合治疗颈椎病的前瞻性研究

目的探讨颈椎前路椎间短节段自体骨融合治疗颈椎病附加内固定的必要性。方法将81例需行颈前路短节段自体骨融合手术治疗的颈椎病患者随机分为单纯植骨及附加钛板内固定两组,随访55例患者,单纯植骨组23例,内固定组32例。随访时间(22±7)个月。采用JOA评分判定手术疗效, X线片判定融合效果、椎间高度变化和颈椎生理曲度变化。结果JOA评分改善率单纯植骨组68%,内固定组58% (P>0 05)。植骨融合率单纯植骨组93% ( 27 /29 ),内固定组100%。椎间高度单纯植骨组下降(0 7±1 0)mm,内固定组增加( 1 2±0 6 )mm (P<0 01 )。颈椎生理曲度单纯植骨组术后较术前减少(0 5±3 2)°, 内固定组术后较术前增加(2 7±7 8)°(P>0 05)。结论颈椎前路椎间短节段自体骨融合附加内固定治疗颈椎病有一定意义。     

A long-term (4- to 12-year) follow-up study of surgical treatment of lumbar spinal stenosis

Limited data are available about the long-term outcome of surgical treatment for lumbar spinal stenosis, and there is a wide variation in reported success rates. There is also a controversy regarding differences in long-term outcome between patients undergoing decompressive surgery alone and those undergoing both decompression and fusion. The aim of this study was to evaluate the long-term clinical outcome and possible complications of decompressive surgery, with special reference to possible differences between patients undergoing fusion, with or without instrumentation, and those undergoing decompression alone. All 124 patients undergoing first-time surgery for lumbar spinal stenosis between 1982 and 1991 at our department were included, and their medical records were reviewed retrospectively. Ninety-six of the patients were available for follow-up and were re-examined by an independent investigator and assessed with a questionnaire after a mean follow-up period of 7.1 (range 4.0–12.2) years. Sixty-five percent of all the patients at the follow-up were subjectively satisfied. Eighty-eight percent of the patients reported constant or daily leg pain preoperatively compared to 43% at follow-up. Constant or daily low back pain was reported by 83% of the patients preoperatively compared to 45% at follow-up. Improvement in walking capacity was found in most patients, and only 4% of the patients who had a preoperatively documented maximum walking distance reported a decreased walking capacity. Twenty-four (25%) of all patients used analgesics daily at the time of follow-up, 34 patients (35%) occasionally and 38 patients (40%) never. The patients with fusions, instrumented or non-instrumented, did not differ significantly from the unfused patients regarding any of the above-mentioned parameters. The results of the study showed that most patients demonstrated a considerable improvement in walking capacity at follow-up. This improvement was significant (P < 0.001) and of clinical importance. A significant improvement regarding both low back pain and leg pain was found postoperatively compared to preoperatively (P < 0.001). There were no statistical differences, judged by all the evaluated parameters, regarding the clinical outcome between patients who were fused and those who were not. Neither were any significant differences found between instrumented fusions compared to uninstrumented fusions. In accordance with most other long-term follow-up studies, about two-thirds (65%) of the patients claimed a satisfactory result at follow-up. Received: 1 March 1999 Revised: 16 March 2000 Accepted: 23 March 2000     

Evaluation of lumbar stiffness after long-level fusion for degenerative lumbar scoliosis via a Chinese version of the lumbar stiffness disability index

BACKGROUND CONTEXTLong-level spinal fusion for degenerative lumbar scoliosis (DLS)seeks to eliminate spinal motion in an attempt to alleviate pain, improve deformity, and reduce disability. However, this surgery considerably impairs the performance of activities of daily living (ADL) due to the resulting stiffness. The lumbar stiffness disability index (LSDI) is a validated measure of the effect of lumbar stiffness on functional activity, but this index might not be fully applicable to the elderly Chinese population given several specific lifestyle characteristics.PURPOSETo evaluate lumbar stiffness in patients with DLS after long-level fusion by Chinese-LSDI (C-LSDI).STUDY DESIGNA retrospective study.PATIENT SAMPLEA total of 129 DLS patients who underwent long-level (≧4 levels) fusion surgery with at least one-year follow-up from June 2009 to September 2017 were retrospectively included.OUTCOME MEASURESThe C-LSDI was designed by modifying LSDI and Korean-LSDI (K-LSDI) based on elderly Chinese lifestyles and the internal consistency and retest repeatability of the patient-reported outcome questionnaire in the measurement of the impact of lumbar stiffness on functional abilities was assessed.METHODSThe radiographic parameters including Cobb angle, apical vertebral translation (AVT), coronal vertical axis (CVA), sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), and PI-LL, and clinical symptoms including visual analogue scale (VAS) for back and low extremity pain; Oswestry disability index (ODI), Japanese Orthopedic Association-29 (JOA–29), Scoliosis Research Society⁃22 (SRS–22), 36⁃Item short form survey (SF–36), physical component scores (PCS) and mental component scores (MCS) were measured preoperatively and at the last follow-up.RESULTSCompared with LSDI and K-LSDI, the C-LSDI demonstrated higher internal consistency (Cronbach's alpha=0.902) and retest reliability (Internal consistency coefficients, ICC=0.904) in the elderly Chinese population. All patients showed increased lumbar stiffness and significant improvement in pain and deformity postoperatively. Regarding items, such as performing personal hygiene after toileting and getting out of a car, people reported more inconvenience with increasingly fixed levels.CONCLUSIONSThis study demonstrated that the C-LSDI questionnaire was a reliable and valid instrument for assessing functional limitations due to lumbar stiffness among elderly Chinese patients with DLS after long-level fusion. Although the effects of stiffness did trend toward greater impacts among patients who underwent longer fusions, most patients were satisfied with trade-offs of function and pain relief in exchange for perceived increases in lumbar stiffness.     

The efficacy of rhBMP-2 versus autograft for posterolateral lumbar spine fusion in elderly patients

Few studies have specifically examined the outcomes following rhBMP-2 usage in patients 65 years and older. The purpose of this retrospective study is to evaluate the efficacy of rhBMP-2 with allograft versus autograft for posterolateral lumbar fusion in patients 65 years and older. One hundred twenty-seven patients were divided into three groups based on fusion material and age. Subjects in group A (n = 34) consisted of patients 65 years and older who received rhBMP-2 and allograft. Group B (n = 52) was composed of patients under 65 years of age with rhBMP-2 and allograft. Subjects in group C (n = 41) were 65 years and older with autograft use. A comparison was made of fusion rate, fusion time (noticed, solid), clinical outcome, VAS, perioperative complications and revision rate between each group. The fusion rate and fusion time were similar in groups A and C; however, these were lower than that observed in group B. Clinical outcomes were similar amongst the groups. There were no significant differences in VAS and perioperative complication rate between groups A and C. In patients 65 years and older, rhBMP-2 with allograft may lead to acceptable fusion rates and fusion times, good clinical outcomes and reduced perioperative complications. The combination of rhBMP-2 with allograft yields equivalent outcomes as autograft in elderly patients undergoing instrumented posterolateral lumbar fusion. Additionally, when compared to patients under 65 years of age undergoing posterolateral lumbar fusion, the use of rhBMP-2 was not sufficient to overcome all aspects of the age-related weakened osteoinductive capacity encountered in elderly patients.     

Thoracal flat back is a risk factor for lumbar disc degeneration after scoliosis surgery

Background contextLumbar segments below fused scoliotic spines are thought to be exposed to extraordinary stress. Although positive sagittal imbalance has come into focus, reports about factors influencing the outcome of these segments remain inconclusive.PurposeOur study aimed at identifying spinal risk factors for the development of lumbar degenerative disc disease (DDD) in surgically treated patients with adolescent idiopathic scoliosis (AIS).Study design/settingRetrospective comparative prognostic study (Level III) was conducted. Thirty-three patients were seen at an average follow-up of 7.5 years after either isolated selective anterior (n=18) or long combined anterior-posterior fusion (n=15) for AIS.Outcome measuresSelf-reported Scoliosis Research Society 22 questionnaire, physical examination including the detection of segmental pain and unspecific back pain, preoperative and postoperative whole-spine standing radiographs, and magnetic resonance imaging were obtained.MethodsRadiographic evaluation included the measurement of regional, coronal, and sagittal curve parameters and the assessment of spinal balance. Magnetic resonance imaging evaluation was done for preoperative and postoperative lumbar discs, according to the classification of Pfirrmann.ResultsPatients with low DDD (Pfirrmann grading <3) had a significantly higher thoracal kyphosis angle (mean 28°) than patients with advanced DDD (mean 15°). There was a trend toward a more flat-type lumbar lordosis in patients with severe DDD. Positive sagittal imbalance was associated with advanced DDD. Follow-up coronal parameters, trunk imbalance, instrumentation length, and lowest instrumented vertebra selection had no influence on DDD. Specific segmental pain could be attributed to a significantly higher coronal trunk imbalance (21 vs. 11 mm).ConclusionsThis study establishes thoracal flat back as a risk factor for lumbar DDD after spinal fusion and supports the pathogenetic role of positive sagittal imbalance in this process.     

Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis

Introduction

Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomatic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature.

Methods

Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up.

Results

Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD − 0.31, 95% CI − 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD − 1.79, 95% CI − 5.08 to 1.50) or back pain (MD − 2.54, 95% CI − 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion.

Conclusion

Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).

     

Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Pain drawings have been used in spine surgery for diagnostic use and psychological evaluation of fusion candidates; they have rarely been used to evaluate pain status after spinal fusion. This study is a 5-year follow-up on a randomised clinical trial assigning patients to posterolateral spinal fusion with or without pedicle screw instrumentation. Patients were mailed a pain drawing and questionnaires including questions regarding work, social status, smoking status, the Dallas Pain Questionnaire (DPQ), and the Low Back Pain Rating Scale (LBPRS). Pain drawings were scored using a visual inspection method and a surface-based point scoring and evaluated for the presence of donor site pain. Pain drawings from 109 patients (87% of the initially included patients), 56 men and 53 women, mean age at follow-up 51 years, were analysed. Fifty-three patients had undergone an instrumented fusion and 56 a non-instrumented fusion. Some presence of low back pain was marked by 79% and leg pain by 69%. Sixty-two percent of the pain drawings were classified as "organic" and 38% as "non-organic". There was no difference between the instrumented and the uninstrumented group. DPQ and LBPRS scores were higher in the non-organic group ( P=0.007). Using the point scoring, no difference between the instrumented and the uninstrumented group was seen. The results of the point scoring were found to correlate with the DPQ and LBPRS scores ( P=0.001). Working patients (39%) had significantly better scores than the rest. Ten percent of the patients had donor site pain. Twenty percent of spinal fusion patients are totally pain free at 5-year follow-up. Ten percent still experience donor site pain. In general, instrumentation does not affect the amount and localisation of pain 5 years after lumbar spinal fusion surgery. The pain drawing seems to be a valuable tool when following spinal fusion patients, but its use as prognostic marker in connection with fusion surgery needs further investigation.