Showing papers in "Spine in 2017"
TL;DR: MIS using robotic-guidance significantly reduced radiation exposure and length of stay and patient outcomes were not affected by the surgical technique.
Abstract: STUDY DESIGN A prospective randomized clinical trial. OBJECTIVE To compare the impact of robotic guidance in a minimally invasive spine surgery (MIS) to a fluoroscopy-guided open approach in lumbar fusions. SUMMARY OF BACKGROUND DATA MIS requires a protracted learning curve and excessively exposes the patient and surgical team to harmful radiation. Robotic-guidance has been shown to improve accuracy and radiation in most studies, but there is conflicting prospective data. METHODS Patients indicated to undergo a 1 or 2 level spinal fusion were randomized between robotic-guided MIS (RO) and fluoroscopic-guided open surgery (FA). Patient demographics and outcomes were recorded. RESULTS Thirty patients were recruited to each arm. Average age was 66.7 years, 71.5% were females, and average body mass index was 25.2. Thirty-five levels were instrumented with 130 pedicle screws in RO versus 40 levels with 140 screws in FA, or 4.3 and 4.7 screws per surgery, respectively. Use of fluoroscopy was 3.5 versus 13.3 seconds in the RO and FA respectively (P 2 mm and >4 mm) in FA (P = 0.500). One proximal facet violation occurred in the study, it was in FA (P = 1.000). The average distance from the proximal facets was 5.8 versus 4.6 mm in the RO and FA respectively (P < 0.001). The average length of stay was 6.8 versus 9.4 days in RO compared with FA (P = 0.020). CONCLUSION MIS using robotic-guidance significantly reduced radiation exposure and length of stay. Patient outcomes were not affected by the surgical technique. LEVEL OF EVIDENCE 1.
209 citations
TL;DR: One that the authors will refer to break the boredom in reading is choosing clinical biomechanics of the spine as the reading material.
Abstract: Introducing a new hobby for other people may inspire them to join with you. Reading, as one of mutual hobby, is considered as the very easy hobby to do. But, many people are not interested in this hobby. Why? Boring is the reason of why. However, this feel actually can deal with the book and time of you reading. Yeah, one that we will refer to break the boredom in reading is choosing clinical biomechanics of the spine as the reading material.
205 citations
TL;DR: The analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors.
Abstract: Study design A retrospective multicenter survey. Objective To investigate the perioperative complications of oblique lateral interbody fusion (OLIF) surgery. Summary of background data OLIF has been widely performed to achieve minimally invasive, rigid lumbar lateral interbody fusion. The associated perioperative complications are not yet well described. Methods The participants were patients who underwent OLIF surgery under the diagnosis of degenerative lumbar diseases between April 2013 and May 2015 at 11 affiliated medical institutions. The collected data were classified into intraoperative and early-stage postoperative (≤1 mo) complications. The intraoperative complications were then subcategorized into organ damage (neural, vertebral, vascular, and others) and other complications, mainly related to instrumental failure. The collected data were also divided and analyzed based on whether the surgeon was certified to perform the surgery and the incidence of complications in the early (April 2013-March 2014) and late stages (April 2014-May 2015) of OLIF introduction. Results In the 155 included patients, 75 complications were reported (incidence rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%), followed by transient psoas weakness and thigh numbness (13.5%) and segmental artery injury (2.6%). Almost all these complications were transient, except for three patients who had permanent damage: one had ureteral injury and two had neurological injury. Postoperative complications included surgical site infection (1.9%) and reoperation (1.9%). Whether the primary operator was experienced did not affect the incidence of complications. Regarding the introductory stage, the incidence of complications was 50% in the early stage and 38% in the late stage. Conclusion The overall incidence of perioperative complications of OLIF surgery reached 48.3%, of which only 1.9% resulted in permanent damage. Our analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors. Level of evidence 3.
176 citations
TL;DR: Overall, this study suggests that PJK patients were overcorrected when compared to age-adjusted alignment goals, emphasizing the need for surgeons to incorporate age-specific alignment targets into the standard preoperative planning process.
Abstract: STUDY DESIGN Retrospective cohort. OBJECTIVE To explore proximal junctional kyphosis (PJK) as a function of age-adjusted surgical correction goals. SUMMARY OF BACKGROUND DATA Recent adult spinal deformity (ASD) studies show that alignment targets are age-specific. Despite recognizing age and malalignment as PJK risk factors, no study has assessed the age-specific effects of alignment on PJK. METHODS ASD patients with fusions to the pelvis were included and stratified into three groups: young adults (YA 65 years old). Analysis of variance compared the groups with respect to 1-year postoperative alignments and 1-year offsets from age-specific alignment targets. RESULTS A total of 679 patients were enrolled (mean age = 61 years old, 77% female, body mass index = 28.1). At 1 year postoperatively, there was a significant decrease in pelvic tilt (PT; 29-23°), spinopelvic mismatch (pelvic incidence [PI]-lumbar lordosis [LL]) (28-5°), and sagittal vertical axis (SVA; 110-37 mm); overall incidence of PJK was 45.1%. Stratification by age (YA, n = 28; MA, n = 389; ED, n = 262) revealed an increase in PJK incidence with age: YA = 17.9%, MA = 43.8%, and ED = 50.2% (P < 0.001). PJK patients had smaller postoperative PI-LL mismatches (ED 0.8° vs. 9.8°, MA 3.1° vs. 7.3°) than non-PJK patients, without any significant differences in PT or SVA. Analysis of the postoperative offsets from age-specific norms revealed that PJK patients in the two older subgroups and in the study cohort as a whole were overcorrected as compared to non-PJK patients (PI-LL offset-all: -5.2° vs. 2.8°, MA: -1° vs. +4°, ED: -11° vs. -2°; SVA offset-all: -10 mm vs. 7 mm, MA: -3 mm vs. 10 mm, ED: -18 mm vs. -6 mm). The correlation coefficients between PJK angles and the offsets from age-adjusted objective were small (0.320 for PI-LL, 0.114 for PT, and 0.136 for SVA). CONCLUSION Overall, this study suggests that PJK patients were overcorrected when compared to age-adjusted alignment goals. Certainly, elderly patients are subject to independent risk factors for PJK, making the prevention of PJK complex. However, individualized optimization of surgical alignment can improve outcomes. This emphasizes the need for surgeons to incorporate age-specific alignment targets into the standard preoperative planning process. LEVEL OF EVIDENCE 3.
132 citations
TL;DR: The PROMIS PF CAT outperforms the ODI and SF-36 PFD in the spine patient population and is highly correlated, while taking less time to administer with fewer questions to answer.
Abstract: Study design The Oswestry Disability Index v20 (ODI), SF36 Physical Function Domain (SF-36 PFD), and PROMIS Physical Function CAT v12 (PF CAT) questionnaires were prospectively collected from 1607 patients complaining of back or leg pain, visiting a university-based spine clinic All questionnaires were collected electronically, using a tablet computer Objective The aim of this study was to compare the psychometric properties of the PROMIS PF CAT with the ODI and SF36 Physical Function Domain in the same patient population Summary of background data Evidence-based decision-making is improved by using high-quality patient-reported outcomes measures Prior studies have revealed the shortcomings of the ODI and SF36, commonly used in spine patients The PROMIS Network has developed measures with excellent psychometric properties The Physical Function domain, delivered by Computerized Adaptive Testing (PF CAT), performs well in the spine patient population, though to-date direct comparisons with common measures have not been performed Methods Standard Rasch analysis was performed to directly compare the psychometrics of the PF CAT, ODI, and SF36 PFD Spearman correlations were computed to examine the correlations of the three instruments Time required for administration was also recorded Results One thousand six hundred seven patients were administered all assessments The time required to answer all items in the PF CAT, ODI, and SF-36 PFD was 44, 169, and 99 seconds The ceiling and floor effects were excellent for the PF CAT (081%, 386%), while the ceiling effects were marginal and floor effects quite poor for the ODI (691% and 4424%) and SF-36 PFD (597% and 2365%) All instruments significantly correlated with each other Conclusion The PROMIS PF CAT outperforms the ODI and SF-36 PFD in the spine patient population and is highly correlated It has better coverage, while taking less time to administer with fewer questions to answer Level of evidence 2
122 citations
TL;DR: Although the majority of complications were minor, a relatively high rate of complications was reported and approach-related specific features of the two procedures were identified.
Abstract: Study Design.Retrospective nationwide questionnaire-based survey of complications.Objective.To elucidate the incidence of complications and risk factors associated with lateral interbody fusion (LIF).Summary of Background Data.After its introduction to Japan in February 2013, the numbers of LIF case
114 citations
TL;DR: Lumbar muscle fat content, but not CSA, changes with age in individuals with pathology, and in women, this increase is more profound than age-related increases in healthy individuals.
Abstract: Author(s): Shahidi, Bahar; Parra, Callan L; Berry, David B; Hubbard, James C; Gombatto, Sara; Zlomislic, Vinko; Allen, R Todd; Hughes-Austin, Jan; Garfin, Steven; Ward, Samuel R | Abstract: Study designRetrospective chart analysis of 199 individuals aged 18 to 80 years scheduled for lumbar spine surgery.ObjectiveThe purpose of this study was to quantify changes in muscle cross-sectional area (CSA) and fat signal fraction (FSF) with age in men and women with lumbar spine pathology and compare them to published normative data.Summary of background dataPathological changes in lumbar paraspinal muscle are often confounded by age-related decline in muscle size (CSA) and quality (fatty infiltration). Individuals with pathology have been shown to have decreased CSA and fatty infiltration of both the multifidus and erector spinae muscles, but the magnitude of these changes in the context of normal aging is unknown.MethodsIndividuals aged 18 to 80 years who were scheduled for lumbar surgery for diagnoses associated with lumbar spine pain or pathology were included. Muscle CSA and FSF of the multifidus and erector spinae were measured from preoperative T2-weighted magnetic resonance images at the L4 level. Univariate and multiple linear regression analyses were performed for each outcome using age and sex as predictor variables. Statistical comparisons of univariate regression parameters (slope and intercept) to published normative data were also performed.ResultsThere was no change in CSA with age in either sex (P g 0.05), but women had lower CSAs than men in both muscles (P l 0.0001). There was an increase in FSF with age in erector spinae and multifidus muscles in both sexes (P l 0.0001). Multifidus FSF values were higher in women with lumbar spine pathology than published values for healthy controls (P = 0.03), and slopes tended to be steeper with pathology for both muscles in women (P l 0.08) but not in men (P g 0.31).ConclusionLumbar muscle fat content, but not CSA, changes with age in individuals with pathology. In women, this increase is more profound than age-related increases in healthy individuals.Level of evidence3.
114 citations
TL;DR: The findings may provide clinically relevant information to physicians, patients, and their families regarding the risk factors for opioid dependence following lumbar fusion surgery.
Abstract: Study Design.A population-based retrospective cohort study.Objective.The aim of this study was to examine risk factors for long-term opioid use following lumbar spinal fusion surgery in a nationally representative cohort of commercially insured adults.Summary of Background Data.Opioid prescription r
110 citations
TL;DR: Machine learning in the form of logistic regression and ANNs were more accurate than benchmark ASA scores for identifying risk factors of developing complications following posterior lumbar spine fusion, suggesting they are potentially great tools for risk factor analysis in spine surgery.
Abstract: Study design A cross-sectional database study. Objective The aim of this study was to train and validate machine learning models to identify risk factors for complications following posterior lumbar spine fusion. Summary of background data Machine learning models such as artificial neural networks (ANNs) are valuable tools for analyzing and interpreting large and complex datasets. ANNs have yet to be used for risk factor analysis in orthopedic surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent posterior lumbar spine fusion. This query returned 22,629 patients, 70% of whom were used to train our models, and 30% were used to evaluate the models. The predictive variables used included sex, age, ethnicity, diabetes, smoking, steroid use, coagulopathy, functional status, American Society for Anesthesiology (ASA) class ≥3, body mass index (BMI), pulmonary comorbidities, and cardiac comorbidities. The models were used to predict cardiac complications, wound complications, venous thromboembolism (VTE), and mortality. Using ASA class as a benchmark for prediction, area under receiver operating curves (AUC) was used to determine the accuracy of our machine learning models. Results On the basis of AUC values, ANN and LR both outperformed ASA class for predicting all four types of complications. ANN was the most accurate for predicting cardiac complications, and LR was most accurate for predicting wound complications, VTE, and mortality, though ANN and LR had comparable AUC values for predicting all types of complications. ANN had greater sensitivity than LR for detecting wound complications and mortality. Conclusion Machine learning in the form of logistic regression and ANNs were more accurate than benchmark ASA scores for identifying risk factors of developing complications following posterior lumbar spine fusion, suggesting they are potentially great tools for risk factor analysis in spine surgery. Level of evidence 3.
110 citations
TL;DR: Prophylactic Intraoperative local vancomycin powder reduces the risk and morbidity of SSI in patients undergoing instrumented spine surgery and is recommended in larger populations involving other spine surgeries with a long-term follow-up duration.
Abstract: STUDY DESIGN This is a retrospective cohort comparative study of all patients who underwent instrumented spine surgery at a single institution OBJECTIVE To compare the rate of surgical site infection (SSI) between the treatment (vancomycin) and the control group (no vancomycin) in patients undergoing instrumented spine surgery SUMMARY OF BACKGROUND DATA SSI after spine surgery is a dreaded complication associated with increased morbidity and mortality Prophylactic intraoperative local vancomycin powder to the wound has been recently adopted as a strategy to reduce SSI but results have been variable METHODS In the present study, there were 117 (30%) patients in the treatment group and 272 (70%) patients in the comparison cohort All patients received identical standard operative and postoperative care procedures based on protocolized department guidelines The present study compared the rate of SSI with and without the use of prophylactic intraoperative local vancomycin powder in patients undergoing various instrumented spine surgery, adjusted for confounders RESULTS The overall rate of SSI was 47% with a decrease in infection rate found in the treatment group (09% vs 63%) This was statistically significant (P = 0049) with an odds ratio of 013 (95% confidence interval 002-099) The treatment group had a significantly shorter onset of infection (5 vs 167 days; P < 0001) and shorter duration of infection (85 vs 268 days; P < 0001) The most common causative organism was Pseudomonas aeruginosa (352%) Patient diagnosis, surgical approach, and intraoperative blood loss were significant risk factors for SSI after multivariable analysis CONCLUSION Prophylactic Intraoperative local vancomycin powder reduces the risk and morbidity of SSI in patients undergoing instrumented spine surgery P aeruginosa infection is common in the treatment arm Future prospective randomized controlled trials in larger populations involving other spine surgeries with a long-term follow-up duration are recommended LEVEL OF EVIDENCE 3
109 citations
TL;DR: The Minimal Clinically Important Difference (MCID) for the physical (PCS) and mental (MCS) component summaries of Short Form SF-12, in patients with low back pain (LBP), is estimated and is smaller in patientsWith longer pain duration and better baseline quality of life.
Abstract: Study design Multicenter, prospective, cohort study. Objective To estimate the Minimal Clinically Important Difference (MCID) for the physical (PCS) and mental (MCS) component summaries of Short Form SF-12 (SF-12), in patients with low back pain (LBP). Summary of background data Quality of life is one of the core domains recommended to be assessed in patients with LBP. SF-12 is the most widely used instrument for this purpose, but its MCID was unknown. Methods A total of 458 patients with subacute and chronic LBP were consecutively recruited across 21 practices. LBP, referred pain, disability, PCS, and MCS were assessed upon recruitment and 12 months later. Self-reported health status change between baseline and 12 month-assessment, was used as the external criterion. The MCID for SF-12 was estimated following four anchor-based methods; minimal detectable change (MDC); average change (AC); change difference (CD); and receiver operating characteristic curve (ROC), for which the area under the curve (AUC) was calculated. The effect on MCID values of pain duration and baseline scores was assessed. Results Values for PCS were: MDC: 0.56, AC: 2.71, CD: 3.29, and ROC: 1.14. Values for MCS were: MDC: 3.77, AC: 3.54, CD: 1.13, and ROC: 4.23. AUC values were Conclusion Different methods for MCID calculation lead to different results. In patients with subacute and chronic LBP, improvements >3.77 in MCS and >3.29 in PCS, can be considered clinically relevant. MCID is smaller in patients with longer pain duration and better baseline quality of life. Level of evidence 2.
TL;DR: The results demonstrate a loss of discrete motor cortical organization of the paraspinal muscles in chronic LBP that can be identified using noninvasive EMG recordings and suggest that surface EMG positioned at L3 is appropriate for the identification of changes in the motor cortex in LBP.
Abstract: Study Design. Cross-sectional design. Objective. Here we aimed to determine whether motor cortical reorganization in low back pain (LBP) can be identified using noninvasive surface electromyographic (EMG) recordings of back muscles at different lumbar levels, and whether cortical reorganization is related to clinical features of LBP. Summary of Background Data. Reorganization of motor regions of the brain may contribute to altered motor control, pain, and disability in chronic LBP. However, data have been limited by the need for invasive recordings of back muscle myoelectric activity. The relationship between altered cortical organization and clinical features of LBP remains unclear. Methods. In 27 individuals with recurrent, nonspecific LBP and 23 pain-free controls, we mapped the motor cortical representation of the paraspinal muscles using transcranial magnetic stimulation in conjunction with noninvasive surface EMG recordings at L3 and L5 levels. Clinical measures of pain severity, location, and duration were made. Results. The results demonstrate a loss of discrete motor cortical organization of the paraspinal muscles in chronic LBP that can be identified using noninvasive EMG recordings. A loss of discrete cortical organization was clearer when surface electrodes were positioned at L3 rather than L5. A novel finding was that altered motor cortical organization (number of discrete peaks and map volume) was associated with the severity and location of LBP. Conclusion. These data suggest that surface EMG positioned at L3 is appropriate for the identification of changes in the motor cortex in LBP. Furthermore, our data have implications for treatment strategies that aim to restore cortical organization in LBP.
TL;DR: The use of the S2AI technique over the IS technique was an independent predictor of preventing reoperation and SSI, while achieving similar clinical and functional outcomes.
Abstract: Study design Retrospective comparative study. Objective To compare clinical and radiographic outcomes between the S2-alar-iliac (S2AI) and the iliac screw (IS) techniques in the adult population and clarify the clinical strength of S2AI screws. Summary of background data S2AI screws have been described as an alternative method for lumbosacropelvic fixation in place of ISs. The S2AI technique has several advantages with lower prominence, increased ability to directly connect to proximal instrumentation, less extensive dissection of tissue, and enhanced biomechanical strength over the IS technique. However, the clinical significance of these advantages remains unclear. Methods A single-center retrospective review of patients who underwent lumbosacropelvic fixation yielded 25 IS group patients and 65 S2AI group patients. Baseline demographic information, postoperative complications, pain and functional outcomes, and screw-related outcomes were collected. Results The S2AI group had lower rates of reoperation (8.8% vs. 48.0%, P Conclusion The use of the S2AI technique over the IS technique was an independent predictor of preventing reoperation and SSI, while achieving similar clinical and functional outcomes. Level of evidence 4.
TL;DR: Those considering revision surgery for reherniation will likely improve significantly following surgery, but possibly not as much as with primary discectomy, and younger patients with higher baseline disability without neurological deficit are at increased risk of undergoing revisions surgery forReherniation.
Abstract: STUDY DESIGN This study was a post-hoc subgroup analysis of prospectively collected data in the Spine Patient Outcomes Research Trial (SPORT). OBJECTIVE The aim of this study was to determine the risk factors for and to compare the outcomes of patients undergoing revision disc excision surgery in SPORT. SUMMARY OF BACKGROUND DATA Risk factors for reherniation and outcomes after revision surgery have not been well-studied. This information is critical for proper patient counseling and decision-making. METHODS Patients who underwent primary discectomy in the SPORT intervertebral disc herniation cohort were analyzed to determine risk factors for undergoing revision surgery. Risk factors for undergoing revision surgery for reherniation were evaluated using univariate and multivariate analysis. Primary outcome measures consisted of Oswestry Disability Index (ODI), the Sciatica Bothersomeness index (SBI), and the Short Form 36 (SF-36) at 6 weeks, 3 months, 6 months, and yearly to 4 years. RESULTS Of 810 surgical patients, 74 (9.1%) received revision surgery for reherniation. Risk factors for reherniation included: younger age (hazard ratio [HR] 0.96 [0.94-0.99]), lack of a sensory deficit (HR 0.61 [0.37-0.99]) lack of motor deficit (HR 0.54 [0.32-0.91]), and higher baseline ODI score (HR 1.02 [1.01-1.03]). The time-adjusted mean improvement from baseline to 4 years was less for the reherniation group on all outcome measures (Bodily Pain Index [BP] 39.5 vs. 44.9, P = 0.001; Physical Function Index [PF] 37.1 vs. 44.5, P < 0.001; ODI 33.9 vs. 38.3, P < 0.001; SBI 8.7 vs. 10.5, P < 0.001). At 4 years, only SBI (-9 vs. -11.4, P = 0.002) was significantly lower in the reherniation group. CONCLUSION Younger patients with higher baseline disability without neurological deficit are at increased risk of undergoing revision surgery for reherniation. Those considering revision surgery for reherniation will likely improve significantly following surgery, but possibly not as much as with primary discectomy. LEVEL OF EVIDENCE 3.
TL;DR: The various determinations of MCID and its usage in the spine literature of the past 5 years are summarized in order to develop a basic reference to help practitioners interpret or utilize MCID.
Abstract: Study design Review of the 2011 to 2015 minimum clinically important difference (MCID)-related publications in Spine, Spine Journal, Journal of Neurosurgery-Spine, and European Spine Journal. Objective To summarize the various determinations of MCID and to analyze its usage in the spine literature of the past 5 years in order to develop a basic reference to help practitioners interpret or utilize MCID. Summary of background data MCID represents the smallest change in a domain of interest that is considered beneficial to a patient or clinician. The many sources of variation in calculated MCID values and inconsistency in its utilization have resulted in confusion in the interpretation and use of MCID. Methods All articles from 2011 to 2015 were reviewed. Only clinical science articles utilizing patient reported outcome scores (PROs) were included in the analysis. A keyword search was then performed to identify articles that used MCID. MCID utilization in the selected papers was characterized and recorded. Results MCID was referenced in 264/1591 (16.6%) clinical science articles that utilized PROs: 22/264 (8.3%) independently calculated MCID values and 156/264 (59.1%) used previously published MCID values as a gauge of their own results. Despite similar calculation methods, there was a two- or three-fold range in the recommended MCID values for the same instrument. Half the studies recommended MCID values within the measurement error. Most studies (97.2%) using MCID to evaluate their own results relied on generic MCID. The few studies using specific MCID (MCID calculated for narrowly defined indications or treatments) did not consistently match the characteristics of their sample to the specificity of the MCID. About 48% of the studies compared group averages instead of individual scores to the MCID threshold. Conclusion Despite a clear interest in MCID as a measure of patient improvement, its current developments and uses have been inconsistent. Level of evidence N/A.
TL;DR: In Australia, decompression rates for lumbar spinal stenosis increased from 2003 to 2013, and the fastest increasing surgical procedure was complex fusion, which increased the risk of major complications and resource, although recent evidence suggest fusion provides no additional benefits to the traditional decompression surgery.
Abstract: Population based health record linkage study.
To determine trends in hospital admissions and surgery for lumbar spinal stenosis, as well as complications and resource use in Australia.
In the United States, rates of decompression surgery have declined, whereas those of fusion have increased. It is unclear whether this trend is also happening elsewhere.
We included patients 18 years and older admitted to a hospital in New South Wales between 2003–2013, who were diagnosed with lumbar spinal stenosis. We investigated the rates of hospital admission and surgical procedures, as well as hospital costs, length of hospital stay, and complications. Surgical procedures were: decompression alone, simple fusion (1–2 disc levels, single approach), and complex fusion (≥3 disc levels or a combined posterior and anterior approach).
The rates of decompression surgery increased from 19.0 to 22.1 per 100,000 people. Simple fusion rates increased from 1.3 to 2.8 per 100,000 people, while complex fusion increased from 0.6 to 2.4 per 100,000 people. The odds of major complications for complex fusion compared with decompression alone was 4.1 (95% CI: 1.7–10.1), though no difference was found for simple fusion (OR 2.0, 95% CI: 0.7–6.1). Mean hospital costs with decompression surgery were AU $12,168, while simple and complex fusion cost AU $30,811 and AU $32,350, respectively.
In Australia, decompression rates for lumbar spinal stenosis increased from 2003–2013. The fastest increasing surgical procedure was complex fusion. This procedure increased the risk of major complications and resource, though recent evidence suggest fusion provides no additional benefits to the traditional decompression surgery.
Level of Evidence: 3
TL;DR: It is demonstrated that MIS resulted in comparable outcome to open surgery for patients with spinal metastasis but has the advantage of less blood loss, blood transfusions, and shorter hospital stay.
Abstract: Study design Prospective propensity score-matched study. Objective To compare the outcomes of minimal invasive surgery (MIS) and conventional open surgery for spinal metastasis patients. Summary of background data There is lack of knowledge on whether MIS is comparable to conventional open surgery in treating spinal metastasis. Methods Patients with spinal metastasis requiring surgery from January 2008 to December 2010 in two spine centers were recruited. The demographic, preoperative, operative, perioperative and postoperative data were collected and analyzed. Thirty MIS patients were matched with 30 open surgery patients using propensity score matching technique with a match tolerance of 0.02 based on the covariate age, tumor type, Tokuhashi score, and Tomita score. Results Both groups had significant improvements in Eastern Cooperative Oncology Group (ECOG), Karnofsky scores, visual analogue scale (VAS) for pain and neurological status postoperatively. However, the difference comparing the MIS and open surgery group was not statistically significant. MIS group had significantly longer instrumented segments (5.5 ± 3.1) compared with open group (3.8 ± 1.7). Open group had significantly longer decompressed segment (1.8 ± 0.8) than MIS group (1.0 ± 1.0). Open group had significantly more blood loss (2062.1 ± 1148.0 mL) compared with MIS group (1156.0 ± 572.3 mL). More patients in the open group (76.7%) needed blood transfusions (with higher average units of blood transfused) compared with MIS group (40.0%). Fluoroscopy time was significantly longer in MIS group (116.1 ± 63.3 s) compared with open group (69.9 ± 42.6 s). Open group required longer hospitalization (21.1 ± 10.8 days) compared with MIS group (11.0 ± 5.0 days). Conclusion This study demonstrated that MIS resulted in comparable outcome to open surgery for patients with spinal metastasis but has the advantage of less blood loss, blood transfusions, and shorter hospital stay. Level of evidence 3.
TL;DR: Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs, and hospitals in the western U.S. were 27% more expensive than those in the Northeast.
Abstract: Study design A retrospective review Objective The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation Summary of background data There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level Methods We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region Results The most common type of cervical spine surgery was anterior fusion (806% of all surgeries) The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (7534 to 7220 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs The wage index was positively correlated with cost, and hospitals in the western US were 27% more expensive than those in the Northeast Conclusion The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013 Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery Level of evidence 3
TL;DR: The advent of new technologies does not appear to alter accuracy of screw placement in this setting, and the lack of difference in accuracy does not imply that the above-mentioned techniques have no added advantages.
Abstract: A retrospective radiological study.
The aim of this study was to evaluate the accuracy of pedicle screw insertion using O-Arm navigation, robotic assistance, or a freehand fluoroscopic technique.
Pedicle screw insertion using either "O-Arm" navigation or robotic devices is gaining popularity. Although several studies are available evaluating each of those techniques separately, no direct comparison has been attempted.
Eighty-four patients undergoing implantation of 569 lumbar and thoracic screws were divided into three groups. Eleven patients (64 screws) had screws inserted using robotic assistance, 25 patients (191 screws) using the O-arm, while 48 patients (314 screws) had screws inserted using lateral fluoroscopy in a freehand technique. A single experienced spine surgeon assisted by a spinal fellow performed all procedures. Screw placement accuracy was assessed by two independent observers on postoperative computed tomography (CTs) according to the A to D Rampersaud criteria.
No statistically significant difference was noted between the three groups. About 70.4% of screws in the freehand group, 69.6% in the O arm group, and 78.8% in the robotic group were placed completely within the pedicle margins (grade A) (P > 0.05). About 6.4% of screws were considered misplaced (grades C&D) in the freehand group, 4.2% in the O-arm group, and 4.7% in the robotic group (P > 0.05). The spinal fellow inserted screws with the same accuracy as the senior surgeon (P > 0.05).
The advent of new technologies does not appear to alter accuracy of screw placement in our setting. Under supervision, spinal fellows might perform equally well to experienced surgeons using new tools. The lack of difference in accuracy does not imply that the above-mentioned techniques have no added advantages. Other issues, such as surgeon/patient radiation, fiddle factor, teaching suitability, etc., outside the scope of our present study, need further assessment.
3.
TL;DR: This largest series with the longest follow-up to date that examines the need for additional unplanned surgery after the initial procedure highlights that MCGR surgery can be associated with unplanned reoperations, and more frequent distractions may be a risk factor.
Abstract: Study Design.A retrospective review of prospectively collected clinical and radiologic data of patients with magnetically controlled growing rods (MCGRs) from a multi-centered study with a minimum of 2-year follow-up.Objective.The aim of this study was to describe the incidence and causes of unplann
TL;DR: Previous reported risk factors for SSI were confirmed in this study while some new independent risk factors were identified significantly associated with SSI following lumbar spinal surgery, including preoperative low serum level of calcium, decreased preoperative and postoperative albumin, and decreased postoperative hemoglobin.
Abstract: Study Design.A retrospective study.Objective.The purpose of this study was to identify the independent risk factors for postoperative surgical site infection (SSI) after posterior lumbar spinal surgery based on the perioperative factors analysis.Summary of Background Data.SSI is one of the most comm
TL;DR: This study reports an overall 4-year reoperation rate of 12.2% after single-level discectomy, and a rate of progression to lumbar fusion following re-exploration discctomy of 38.4% within 4 years of reoperation.
Abstract: Study design Retrospective analysis of national insurance billing database. Objective To examine trends in reoperation after single-level lumbar discectomy. Summary of background data Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy caused by disc herniation. Randomized clinical trials have demonstrated the advantage of discectomy over nonsurgical treatment options, allowing for a more rapid reduction in symptoms. However, population-level data regarding reoperation after single level discectomy is limited. Methods Data were collected using the commercially available PearlDiver software for patients billed with the Current Procedural Terminology code for our index procedure, hemilaminotomy and removal of disc material, between January 2007 and September 2014. The index group was then followed for up to 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Results Analysis of data obtained from 13,654 patient records revealed a rate of additional lumbar surgeries after single-level discectomy of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.9% (370/6274) of patients within 4 years. Patients who received a re-exploration discectomy within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years after the re-exploration discectomy. The average additional cost of lumbar reoperation, as measured by insurance reimbursement, was approximately $11,161 per-patient per year. Conclusion We report an overall 4-year reoperation rate of 12.2% after single-level discectomy. In addition, we report a rate of progression to lumbar fusion following re-exploration discectomy of 38.4% within 4 years of reoperation. Further studies are needed regarding the best treatment algorithm in patients with reherniation or iatrogenic instability after lumbar discectomy. This study should enhance the shared decision making process by providing surgeons and patients with valuable data regarding the frequency and nature of reoperations after discectomy. Level of evidence 3.
TL;DR: The modified frailty index was shown to be an independent predictor of Clavien-Dindo grade IV complications in patients undergoing ACDF or PCF and could be used as a platform upon which more efficient risk stratification could be done with addition of other variables.
Abstract: Study Design.Retrospective study of prospectively collected data.Objective.To investigate the applicability of the modified frailty index (mFI) as a predictor of adverse postoperative events in patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF).Summ
TL;DR: In this paper, the authors compared postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation.
Abstract: Study Design.Systematic review and meta-analysis.Objective.To compare postoperative surgical, radiographic, and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with and without plate fixation.Summary of Background Data.ACDF has evolved significantly over the years,
TL;DR: At 7 and 10 years, cervical arthroplasty compares favorably with ACDF as defined by standard outcomes scores in a highly selected population with radiculopathy.
Abstract: Study design Prospective, randomized, single-center, clinical trial. Objective To prospectively examine the 7- and 10-year outcomes of cervical arthroplasty to anterior cervical discectomy and fusion (ACDF). Summary of background data Degeneration of the cervical discs causing radiculopathy is a frequent source of surgical intervention, commonly treated with ACDF. Positive clinical outcomes are associated with arthrodesis techniques, yet there remains a long-term concern for adjacent segment change. Cervical disc arthroplasty has been designed to mitigate some of the challenges associated with arthrodesis whereas providing for a similar positive neurological outcome. As data has been collected from numerous prospective US FDA IDE trials, longer term outcomes regarding adjacent segment change may be examined. Methods As part of an FDA IDE trial, a single center collected prospective outcomes data on 47 patients randomized in a 1:1 ratio to ACDF or arthroplasty. Results Success of both surgical interventions remained high at the 10-year interval. Both arthrodesis and arthroplasty demonstrated statistically significant improvements in neck disability index, visual analog scale neck and arm pain scores at all intervals including 7- and 10-year periods. Arthroplasty demonstrated an advantage in comparison to arthrodesis as measured by final 10-year NDI score (8 vs. 16, P = 0.0485). Patients requiring reoperation were higher in number in the arthrodesis cohort (32%) in comparison with arthroplasty (9%) (P = 0.055). Conclusion At 7 and 10 years, cervical arthroplasty compares favorably with ACDF as defined by standard outcomes scores in a highly selected population with radiculopathy. Level of evidence 1.
TL;DR: PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life.
Abstract: Study Design.Prospective cohort study.Objective.The aim of this study was to determine the validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains.Summary of Background Data.PROMIS health domains (anxiety, depression, fatigue, pain, physical fu
TL;DR: Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables, which can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs.
Abstract: Study design Retrospective study of prospectively collected data. Objective To identify risk factors for nonhome patient discharge after elective anterior cervical discectomy and fusion (ACDF). Summary of background data ACDF is one of the most performed spinal procedures and this is expected to increase in the coming years. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement applications and subsequently reduce hospital length of stay. Methods The 2011 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into two cohorts based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and extended hospital length of stay. Results A total of 14,602 patients met the inclusion criteria for the study of which 498 (3.4%) had nonhome discharge. Multivariate logistic regression found that Hispanic versus Black race/ethnicity (odds ratio, OR =0.21, 0.05-0.91, P =0.037), American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander versus Black race/ethnicity (OR = 0.52, 0.34-0.80, p-value = 0.003), White versus Black race/ethnicity (OR = 0.55, 0.42-0.71), elderly age ≥65 years (OR = 3.32, 2.72-4.06), obesity (OR = 0.77, 0.63-0.93, P = 0.008), diabetes (OR = 1.32, 1.06-1.65, P = 0.013), independent versus partially/totally dependent functional status (OR = 0.11, 0.08-0.15), operation time ≥4 hours (OR = 2.46, 1.87-3.25), cardiac comorbidity (OR = 1.38, 1.10-1.72, P = 0.005), and ASA Class ≥3 (OR = 2.57, 2.05-3.20) were predictive factors in patient discharge to a facility other than home. In addition, multivariate logistic regression analysis also found nonhome discharge to be the most predictive variable in prolonged hospital length of stay. Conclusion Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables. Identification of these factors can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs. Level of evidence 3.
TL;DR: Investigating the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion found it associated with a 22% decrease in hospital charges in the postoperative period.
Abstract: STUDY DESIGN A retrospective study of consecutive patients. OBJECTIVE The purpose of this study was to determine implementing an accelerated protocol could decrease our average hospital stay and what impact this had on postoperative pain management. SUMMARY OF BACKGROUND DATA To our knowledge, no prior studies have reviewed the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion. METHODS This is a retrospective review of all consecutive patients undergoing posterior spinal fusion (PSF) for AIS before (June 1, 2008-May 31, 2013 = traditional protocol) and after (June 1, 2013-October 22, 2014 = accelerated protocol) protocol implementation. Subjective response to the FACES Pain Intensity scale was collected for each postoperative day while in the hospital by the nursing staff. RESULTS There were 194 patients in the traditional pathway and 90 patients in the accelerated pathway. No significant differences in age at surgery, sex, or number of levels fused were present between the groups. Patients managed under the accelerated discharge had an average hospital stay of 3.7 days compared with 5.0 days for the traditional discharge (P < 0.001). There was no increased incidence of wound complications between the two groups [3.6% (7/194) vs. 3.3% (3/90), P = 0.91] or readmission [1.5% (3/194) vs. 4.4% (4/90), P = 0.213]. Hospital charges for postoperative care were significantly less in the accelerated discharge group than in the traditional group ($18,360 vs. $23,640, P < 0.0001). This corresponded to a 22% ($5280/$23,640) decrease in postoperative hospital charges. Patients had a small (<1 point change on FACES pain scale) but statistically significant increase in pain on postoperative days 2, 3, and 4 (P = 0.0001, P = 0.0079, P = 0.0076). CONCLUSION Accelerated discharge following PSF for AIS was associated with a 22% decrease in hospital charges in the postoperative period. LEVEL OF EVIDENCE 4.
TL;DR: African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery.
Abstract: Study design A retrospective cohort analysis of prospectively collected clinical data. Objective The aim of this study was to assess the effect of race on outcomes in patients undergoing elective laminectomy and/or fusion spine surgery. Summary of background data Studies that have looked at the effect of race on spine surgery outcomes have failed to take into account baseline risk factors that may influence peri-operative outcomes. Methods We identified 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion, from 2006 to 2012, at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity. Pre- and intraoperative characteristics and 30-day outcomes were stratified by race. We used propensity scores to match African-American and Caucasian patients on all pre- and intraoperative factors, including by principal diagnosis leading to surgery as well as surgery performed. We used regular and conditional logistic regression to predict the effect of race on adverse postoperative outcomes in the full sample and matched sample. Results Caucasians comprised 82% of our sample. We found no differences in the incidence of pre- and intraoperative factors when comparing Caucasian patients with all minority patients, and only minimal increased odds for prolonged length of length of hospitalization (LOS) and discharge with continued care. However, African-American patients, who comprised 39% of our minority sample, had more preoperative comorbidities than Caucasian patients. Even after eliminating all differences between pre- and intraoperative factors between Caucasian and African-American patients, African-American patients continued to have LOS that was, on average, one day longer than Caucasian patients. African-American patients also had higher odds for major complications [odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1-1.6], and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8-2.8). Conclusion African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery. Level of evidence 3.
TL;DR: Clinicians may increasingly utilize levels of evidence during their evaluation of each FBSS patient to render the best therapeutic plan, likely resulting in improved long-term pain control and reducing costs by avoiding less effective modalities.
Abstract: Study Design.A significant number of lumbar postsurgical patients continue to suffer persistent pain and limited function and are termed to have “Failed back surgery syndrome” (FBSS). This review evaluates clinical trial data for the treatment of FBSS patients.Objective.Using an evidence-based appro