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Robert F. Heary, Paul A. Anderson and Paul M. Arnold

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Andrea Pietrantonio, Sokol Trungu, Isabella Famà, Stefano Forcato, Massimo Miscusi and Antonino Raco

OBJECTIVE

Lumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.

METHODS

The authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.

RESULTS

Two hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58–77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).

CONCLUSIONS

Bilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients’ symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.

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Atul Goel, Shashi Ranjan, Abhidha Shah, Abhinandan Patil and Ravikiran Vutha

OBJECTIVE

The authors report their current experience with their previously published novel form of treatment in 70 cases of lumbar canal stenosis. The treatment consisted of only fixation of the spinal segments by the transarticular screw fixation technique. No bone, ligament, osteophyte, or disc resection was done for spinal canal and neural foraminal decompression. The proposed treatment is based on the concept that vertical instability that results in telescoping of the facets on physical activity forms the nodal point of pathogenesis of lumbar canal stenosis.

METHODS

During the period June 2014 to May 2018, 70 patients presenting with the classically described symptoms of lumbar canal stenosis were treated surgically by only fixation of involved spinal segments. Apart from clinical and radiological guides, instability was diagnosed on the basis of physical observation of the status of articulation by direct manipulation of bones of the region. The operation involved transarticular insertion of 2 or 3 screws for each articulation. The Oswestry Disability Index and visual analog scale were used to assess the patients before and after surgery and at follow-up. Additionally, a personalized patient satisfaction score was used to assess the outcome of surgery.

RESULTS

Clinical symptomatic recovery was observed in all patients in the immediate postoperative period. During the average follow-up period, 100% of patients had varying degrees of symptomatic relief. The patient satisfaction score suggested that all patients were very satisfied with the surgical procedure. The transarticular fixation technique provided strong spinal segment fixation and a reliable ground for bone arthrodesis. No patient needed any additional modality of treatment or reoperation for recurrence of symptoms.

CONCLUSIONS

Spinal instability is the nodal point of pathogenesis of spinal degeneration–related lumbar canal stenosis. Only fixation of the involved spinal segments is necessary—decompression by bone or soft-tissue resection is not necessary.

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Alessandro Siccoli, Marlies P. de Wispelaere, Marc L. Schröder and Victor E. Staartjes

OBJECTIVE

Patient-reported outcome measures (PROMs) following decompression surgery for lumbar spinal stenosis (LSS) demonstrate considerable heterogeneity. Individualized prediction tools can provide valuable insights for shared decision-making. The authors aim to evaluate the feasibility of predicting short- and long-term PROMs, reoperations, and perioperative parameters by machine learning (ML) methods.

METHODS

Data were derived from a prospective registry. All patients had undergone single- or multilevel mini-open facet-sparing decompression for LSS. The prediction models were trained using various ML-based algorithms to predict the endpoints of interest. Models were selected by area under the receiver operating characteristic curve (AUC). The endpoints were dichotomized by minimum clinically important difference (MCID) and included 6-week and 12-month numeric rating scales for back pain (NRS-BP) and leg pain (NRS-LP) severity and the Oswestry Disability Index (ODI), as well as prolonged surgery (> 45 minutes), extended length of hospital stay (> 28 hours), and reoperations.

RESULTS

A total of 635 patients were included. The average age was 62 ± 10 years, and 333 patients (52%) were male. At 6 weeks, MCID was seen in 63%, 76%, and 61% of patients for ODI, NRS-LP, and NRS-BP, respectively. At internal validation, the models predicted MCID in these variables with accuracies of 69%, 76%, and 85%, and with AUCs of 0.75, 0.79, and 0.92. At 12 months, 66%, 63%, and 51% of patients reported MCID; the observed accuracies were 62%, 74%, and 66%, with AUCs of 0.68, 0.72, and 0.79. Reoperations occurred in 60 patients (9.5%), of which 27 (4.3%) occurred at the index level. Overall and index-level reoperations were predicted with 69% and 63% accuracy, respectively, and with AUCs of 0.66 and 0.61. In 15%, a length of surgery greater than 45 minutes was observed and predicted with 78% accuracy and AUC of 0.54. Only 15% of patients were admitted to the hospital for longer than 28 hours. The developed ML-based model enabled prediction of extended hospital stay with an accuracy of 77% and AUC of 0.58.

CONCLUSIONS

Preoperative prediction of a range of clinically relevant endpoints in decompression surgery for LSS using ML is feasible, and may enable enhanced informed patient consent and personalized shared decision-making. Access to individualized preoperative predictive analytics for outcome and treatment risks may represent a further step in the evolution of surgical care for patients with LSS.

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Martin N. Stienen, Nicolai Maldaner, Holger Joswig, Marco V. Corniola, David Bellut, Peter Prömmel, Luca Regli, Astrid Weyerbrock, Karl Schaller and Oliver P. Gautschi

OBJECTIVE

Patient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the “Timed Up and Go” (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).

METHODS

A prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.

RESULTS

Sixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.

CONCLUSIONS

The TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.

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Praveen V. Mummaneni, Mohamad Bydon, Mohammed Ali Alvi, Andrew K. Chan, Steven D. Glassman, Kevin T. Foley, Eric A. Potts, Christopher I. Shaffrey, Mark E. Shaffrey, Domagoj Coric, John J. Knightly, Paul Park, Michael Y. Wang, Kai-Ming Fu, Jonathan R. Slotkin, Anthony L. Asher, Michael S. Virk, Panagiotis Kerezoudis, Jian Guan, Regis W. Haid and Erica F. Bisson

OBJECTIVE

Since the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.

RESULTS

A total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.

CONCLUSIONS

Current findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

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Siri Sahib Khalsa, Hyeun Sung Kim, Ravindra Singh and Osama Nezar Kashlan

OBJECTIVE

Lumbar central stenosis can theoretically be decompressed with minimal bone removal via an endoscopic approach. Although multiple studies have demonstrated an adequate radiographic decompression, none has quantified the volume of bone removal after endoscopic decompression. The objective of this study was to quantify the 3D volume of bone removed from the lamina and facet joints during endoscopic decompression for lumbar central and lateral recess stenosis.

METHODS

This retrospective study included adults with lumbar spinal stenosis who underwent endoscopic decompression of a single level or 2 noncontiguous lumbar levels. Central stenosis on MRI was graded preoperatively and postoperatively using the Schizas scale. A computer program was developed in MATLAB to semiautomatically perform a 3D volumetric analysis of preoperative and postoperative lumbar CT scans. The volumetric percentage of bone removed from the lamina and facet joints ipsilateral and contralateral to the side of approach was quantified.

RESULTS

Nineteen patients with 21 treated lumbar levels were included in the study. Preoperatively, the number of levels with Schizas stenosis grades B, C, and D were 5, 12, and 4, respectively. Stenosis grades improved postoperatively to grades A, B, C, and D for 17, 3, 1, and 0 levels, respectively. All levels improved by at least 1 stenosis grade. The volumetric percentage of laminar bone removed was 15.5% (95% CI 11.2%–19.8%, p < 0.001) from the ipsilateral lamina and 8.8% (95% CI 5.7%–11.8%, p < 0.001) from the contralateral lamina. The percentage of facet joint resection was 5.3% (95% CI 4.2%–6.4%, p < 0.001) and 4.3% (95% CI 2.2%–6.4%, p < 0.001) for the ipsilateral and contralateral facet joints, respectively. Average pain scores, as measured by the visual analog scale, improved from 7.9 preoperatively to 2.2 by 3–10 months postoperatively (p < 0.001).

CONCLUSIONS

Endoscopic lumbar decompression achieves improvement in the radiographic grade of lumbar central stenosis with minimal bone removal from the lamina and facet joints. Future prospective studies are needed to validate the findings of this study with more comprehensive clinical outcomes.

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Bumsoo Park, Sung-Hyun Noh and Jeong-Yoon Park

OBJECTIVE

With the development of minimally invasive procedures, percutaneous pedicle screw systems have been used to attempt to correct spondylolisthesis. No previous studies have reported on reduction measures using long tab percutaneous pedicle screws for spondylolisthesis. Additional intraoperative correction has been proposed with the “swing” technique. This study was conducted to compare the efficacy of standard minimally invasive transforaminal interbody fusion (MIS-TLIF) with the efficacy of MIS-TLIF with the “swing” technique (MIS-TLIF and swing) in lumbar spondylolisthesis.

METHODS

This was a matched-control study and included 30 consecutive patients who were followed up for 6 months after surgery. Of those patients, 15 were treated with operative reduction via MIS-TLIF with the “swing” technique, whereas the other 15 were treated with the standard MIS-TLIF procedure. The swing technique is a new reduction procedure for use with long tab percutaneous screws. In the swing technique, the entire system is swung back and forth several times after all constructs are placed. Only patients with Meyerding grade I or II lumbar spondylolisthesis were included in the study (18 with grade I and 12 with grade II). Perioperative and clinical outcomes, radiological parameters (Meyerding grade, percentage of slip, slip correction rate, segmental lordosis, and lumbar lordosis) were compared between groups at 6 months after surgery.

RESULTS

Demographic data did not differ significantly between the 2 groups. Postoperative clinical outcomes showed significant improvement in both groups. Postoperative radiological parameters showed that the degree of spondylolisthesis (swing: 4.7% vs standard: 8.9%) and reduction rate (swing: 77.3% vs standard: 57.1%) favored the swing group. The swing technique effectively decreased the degree of spondylolisthesis (swing: 24.1% to 4.7% vs standard: 21.8% to 8.9%). No complications related to the procedure were reported.

CONCLUSIONS

MIS-TLIF with the “swing” technique with long tab percutaneous pedicle screws is a safe and effective reduction method for monosegmental spondylolisthesis. This technique cannot only alleviate symptoms but also achieve nearly completely reduction of slippage.

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Dachling Pang

This review summarizes the classification, anatomy, and embryogenesis of complex spinal cord lipomas, and it describes in some detail the new technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas: whether total resection confers better long-term benefits than partial resection and whether total resection fares better than conservative treatment—i.e., no surgery—for asymptomatic lipomas. Accordingly, the 24-year progression-free survival data of the author and colleagues’ series of over 300 cases of total resection are compared with historical data from multiple series (including the author and colleagues’ own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of nonsurgical treatment of equivalent numbers of patients. These comparisons amply support the author’s recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even this aggressive surgical approach and consequently projects worse results (admittedly of a small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed.