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Francis C. Lovecchio, Avani S. Vaishnav, Michael E. Steinhaus, Yahya A. Othman, Catherine Himo Gang, Sravisht Iyer, Steven J. McAnany, Todd J. Albert, and Sheeraz A. Qureshi

OBJECTIVE

In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology.

METHODS

The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1–2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°–8°, 10°–12°, and 15°–20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted.

RESULTS

A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°–8° cages, 1.6° with 10°–12° cages, and 3.4° with 15°–20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs −0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016).

CONCLUSIONS

Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1–2-level MIS for lumbar degenerative disease.

Free access

Sohrab Virk, Avani S. Vaishnav, Jung Kee Mok, Steven McAnany, Sravisht Iyer, Todd J. Albert, Catherine Himo Gang, and Sheeraz A. Qureshi

OBJECTIVE

Preoperative pain assessment is often used to gauge the amount of disability in patients with lumbar disc herniation. How high preoperative pain scores impact the clinical course and outcomes of patients after lumbar microdiscectomy is not always clear. Here, the authors aimed to determine whether patients reporting higher preoperative pain scores have worse outcomes after lumbar microdiscectomy than those reporting lower preoperative scores.

METHODS

The authors performed a retrospective review of patients with symptomatic lumbar disc herniations that had failed to improve with nonsurgical methods and who had undergone tubular lumbar microdiscectomy. Health-related quality of life (HRQOL) scores had been collected in the preoperative and postoperative period. The anatomical severity of disease was graded based on lumbar disc health (Pfirrmann classification), facet degeneration, thecal sac cross-sectional area, and disc herniation grade. Data on each patient’s narcotic consumption and length of stay were collected. A Student t-test and chi-square test were used to compare patients with high preoperative pain scores (HP cohort) and those with lower preoperative scores (non-HP cohort).

RESULTS

One hundred thirty-eight patients were included in this analysis. The 47 patients in the HP cohort had taken more preoperative opioids (12.0 ± 21.2 vs 3.6 ± 11.1 morphine equivalent doses, p = 0.01). However, there was no statistically significant difference in Pfirrmann classification (p > 0.15), facet grade (p > 0.11), thecal sac cross-sectional area (p = 0.45), or disc herniation grade (p = 0.39) between the HP and non-HP cohorts. The latter cohort had statistically significant higher preoperative PROMIS scores (36.5 ± 7.0 vs 29.9 ± 6.4, p < 0.001), SF-12 mental component summary scores (48.7 ± 11.5 vs 38.9 ± 16.1, p < 0.001), and SF-12 physical component summary scores (PCS; 32.4 ± 8.6 vs 27.5 ± 10.0, p = 0.005), but a lower Oswestry Disability Index (56.4 ± 22.1 vs 35.4 ± 15.5, p < 0.001). There were only two time points after microdiscectomy when the HP cohort had worse HRQOL scores: at the 2-week follow-up for SF-12 PCS scores (32.4 ± 8.6 vs 29.3 ± 7.1, p = 0.03) and the 12-week follow-up for PROMIS scores (45.2 ± 9.5 vs 39.5 ± 7.1, p = 0.01). All other postoperative HRQOL measurements were similar between the two cohorts (p > 0.05).

CONCLUSIONS

A patient’s perceived severity of disease often does not correlate with the actual clinical pathology on imaging. Although patients who report high pain and have a symptomatic lumbar disc herniation may describe their pain as more extreme, they should be counseled that the outcomes of microdiscectomy are positive.

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Pratyush Shahi, Junho Song, Sidhant Dalal, Dimitra Melissaridou, Daniel J. Shinn, Kasra Araghi, Eric Mai, Evan Sheha, James Dowdell, Sheeraz A. Qureshi, and Sravisht Iyer

OBJECTIVE

The objective of this study was to assess the outcomes of minimally invasive lumbar decompression in patients ≥ 80 years of age and compare them with those of younger age groups.

METHODS

This was a retrospective cohort study. Patients who underwent primary unilateral laminotomy for bilateral decompression (ULBD) (any number of levels) and had a minimum of 1 year of follow-up were included and divided into three groups by age: < 60 years, 60–79 years, and ≥ 80 years. The outcome measures were 1) patient-reported outcome measures (PROMs) (visual analog scale [VAS] back and leg, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey [SF-12] Physical Component Summary [PCS] and Mental Component Summary [MCS] scores, and Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF]); 2) percentage of patients achieving the minimal clinically important difference (MCID) and the time taken to do so; and 3) complications and reoperations. Two postoperative time points were defined: early (< 6 months) and late (≥ 6 months).

RESULTS

A total of 345 patients (< 60 years: n = 94; 60–79 years: n = 208; ≥ 80 years: n = 43) were included in this study. The groups had significantly different average BMIs (least in patients aged ≥ 80 years), age-adjusted Charlson Comorbidity Indices (greatest in the ≥ 80-year age group), and operative times (greatest in 60- to 79-year age group). There was no difference in sex, number of operated levels, and estimated blood loss between groups.

Compared with the preoperative values, the < 60-year and 60- to 79-year age groups showed a significant improvement in most PROMs at both the early and late time points. In contrast, the ≥ 80-year age group only showed significant improvement in PROMs at the late time point. Although there were significant differences between the groups in the magnitude of improvement (least improvement in ≥ 80-year age group) at the early time point in VAS back and leg, ODI, and SF-12 MCS, no significant difference was seen at the late time point except in ODI (least improvement in ≥ 80-year group). The overall MCID achievement rate decreased, moving from the < 60-year age group toward the ≥ 80-year age group at both the early (64% vs 51% vs 41% ) and late (72% vs 58% vs 52%) time points. The average time needed to achieve the MCID in pain and disability increased, moving from the < 60-year age group toward the ≥ 80-year age group (2 vs 3 vs 4 months). There was no significant difference seen between the groups in terms of complications and reoperations except in immediate postoperative complications (5.3% vs 4.8% vs 14%).

CONCLUSIONS

Although in this study minimally invasive decompression led to less and slower improvement in patients ≥ 80 years of age compared with their younger counterparts, there was significant improvement compared with the preoperative baseline.

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Philip K. Louie, Basel Sheikh Alshabab, Michael H. McCarthy, Sohrab Virk, James E. Dowdell, Michael E. Steinhaus, Francis Lovecchio, Andre M. Samuel, Kyle W. Morse, Frank J. Schwab, Todd J. Albert, Sheeraz A. Qureshi, Sravisht Iyer, Yoshihiro Katsuura, Russel C. Huang, Matthew E. Cunningham, Yu-Cheng Yao, Karen Weissmann, Renaud Lafage, Virginie Lafage, and Han Jo Kim

OBJECTIVE

The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology.

METHODS

The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience.

RESULTS

The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559–0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606–0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531–0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%.

CONCLUSIONS

This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.