Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015

Effects of suspension exercise training in the treatment of lumbar disk herniation: a systematic review and meta-analysis

Objective

The study aimed to systematically evaluate the efficacy of suspension exercise training (SET) in the treatment of lumbar intervertebral disk herniation and provide a scientific basis for clinical treatment.

Methods

Databases such as CNKI, Chinese Wanfang, PubMed, Cochrane, the Web of Science, and Embase were searched up to June 2024. A quality assessment was performed using the Cochrane Collaboration's risk-of-bias guidelines, and a meta-analysis was conducted using RevMan 5.4 and Stata 17.0.

Results

A total of 11 studies involving 943 patients were included. Suspension exercise training significantly improved the lumbar disk herniation (LDH) visual analog scale (VAS) score (mean difference (MD) = -0.96; 95% confidence interval (CI), -1.10 to-0.82; p < 0.00001, I2  = 23%), the Japanese Orthopedic Association (JOA) score (MD = 3.29, 95% CI, 1.67 to 4.90; p < 0.0001, I2  = 92%), and the Oswestry Disability Index (ODI) score (MD = -5.41, 95% CI, -7.41 to -3.40; p < 0.00001, I2  = 86%). Subgroup analysis of the JOA score showed better efficacy with suspension exercise training combined with traditional Chinese medicine (TCM) (MD = 4.29, 95% CI, 2.73 to 5.86; p < 0.00001, I2  = 80%) compared to suspension exercise training combined with non-TCM (MD = 0.96, 95% CI, 0.49 to 1.43; p < 0.0001, I2  = 0%).

Conclusion

Suspension exercise training significantly improved the VAS score, JOA score, and ODI score of the patients with lumbar disk herniation; however, there was a high degree of heterogeneity in the JOA score and ODI score. Further validation is needed in the future for different populations with lumbar disk herniation, the specific locations of its occurrence, and the combined modality of suspension exercise training.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024554074.

Local drug delivery challenges and innovations in spinal neurosurgery

The development of novel therapeutics in the field of spinal neurosurgery faces a litany of translational challenges. Achieving precise drug targeting within the confined spaces associated with the spinal cord, canal and vertebra requires the development of next generation delivery systems and devices. These must be capable of overcoming inherent barriers related to drug diffusion, whilst concurrently ensuring optimal drug distribution and retention. In this review, we provide an overview of the most recent advances in the therapeutic management of diseases and disorders affecting the spine, including systems and devices capable of releasing small molecules and biopharmaceuticals that help eliminate pain and restore the mechanical function and stability of the spine. We highlight material-based approaches and minimally invasive techniques that can be employed to provide control over drug release kinetics and improve retention. We also seek to explore how the newest advancements in nanotechnology, biomaterials, additive manufacturing technologies and imaging modalities can be employed in this translational pursuit. Finally, we discuss the landscape of clinical trials and recently approved products aimed at overcoming the complexities associated with drug delivery to the spine.

Correlations Between Psychiatric Disorders and Perioperative Outcomes After Lumbar Fusions: An Analysis of the National Inpatient Sample (2009-2020)

BACKGROUND

Preoperative diagnoses of psychiatric disorders have a demonstrated association with higher rates of perioperative complications. However, recent studies examining the influence of psychiatric disorders on lumbar fusion outcomes are scarce. Our objective was to determine the relationship between the most common psychiatric disorders and perioperative outcomes after lumbar fusion.

METHODS

Demographic and perioperative data for patients who underwent lumbar spine fusion between 2009 and 2020 were collected from the National Inpatient Sample database. These patients were divided into 2 groups: those who were previously diagnosed with depression, bipolar disorder, or anxiety, and those who were not. Univariable and multivariable linear and logistic regression models were utilized to analyze the data.

RESULTS

Of 2,877,241 patients identified in the National Inpatient Sample database as having undergone lumbar fusion, 647,951 had diagnosed psychiatric disorders, and the remaining 2,229,290 were the unaffected cohort. On multivariable analysis, patients diagnosed with psychiatric disorders had significantly increased odds of respiratory (odds ratio [OR]:1.09) and urinary (OR: 1.08) complications and experienced higher odds of mechanical injury (OR: 1.27), fusion disorders (OR: 1.62), dural tears (OR: 1.08), postprocedure anemia (OR: 1.29), longer hospital stays, and higher total costs (P < 0.001). Conversely, patients with psychiatric disorders had lower odds of neurologic injury (OR: 0.8) and wound complications (OR: 0.91) (P < 0.05).

CONCLUSIONS

Patients with depression, bipolar disorder, or anxiety exhibited higher rates of certain types of complications. However, they appeared to have fewer neurological injuries and wound complications than patients without these psychiatric disorders. These findings highlight the necessity for additional studies to elucidate underlying reasons for these disparities.

Patient-Specific Acetabular Safe Zones in Total Hip Arthroplasty: External Validation of a Quantitative Approach to Preoperatively Templating Spinopelvic Parameters

Background

Spinopelvic mechanics are critical in total hip arthroplasty; however, there is no established consensus for adjusting acetabular component positioning based on spinopelvic parameters. This study aimed to (1) validate a recently developed Patient-Specific acetabular safe-zone calculator that factors in spinopelvic parameters and (2) compare differences with hip-spine classification targets.

Methods

A total of 3750 patients underwent primary total hip arthroplasty across 3 academic referral centers, with 33 (0.88%) requiring revision for instability. Spinopelvic parameters were measured before initial total hip arthroplasty, and acetabular component position was measured following the index and revision procedures. Most operations employed either computer navigation or robotic assistance (94%). Surgical approaches included both anterior and posterior techniques. Utilizing our recently developed patient-specific safe-zone calculator, theoretical intraoperative positions were calculated and compared to true component positions before and after revision.

Results

Among 33 patients who underwent revision, none dislocated at an average follow-up of 5.1 years. In the external validation cohort, the average absolute differences between the patient-specific safe-zone and the median hip-spine classification recommendation were 3.8° ± 2.1° inclination and 5.0° ± 3.2° version. For the pooled cohort, the absolute differences between the patient-specific safe-zone targets and the prerevision component positions were 7.9° ± 5.1° inclination and 11.4° ± 6.9° version. After revision, the mean absolute differences decreased to 3.6° ± 3.1° inclination and 5.8° ± 3.5° version (P < .001).

Conclusions

A patient-specific approach improved acetabular component positioning accuracy within 6° of version and 4° of inclination of stable, revised hips. Patient-specific safe zones provide quantitative targets for nuanced spinopelvic preoperative planning that may mitigate risk of instability and may indicate use of assisted technologies.

The oswestry disability index in elective single level lumbar fusion: Is 3 months follow up enough?

Background

Prospective, longitudinal collection of patients reported outcomes (PRO) has become an essential metric in orthopedics. Despite the utility of PROs, data collection presents a significant challenge to the healthcare system. There is a need to better understand if serial data collection over a 1 to 2 year postoperative period is truly warranted. The purpose of this study was to determine if continued PRO collection after 3 months postop is needed in patients that underwent lumbar fusion.

Methods

This retrospective study utilized 239 patients that underwent an elective single level lumbar fusion between April 1, 2020 and February 1, 2023. Changes in the Oswestry Disability Index (ODI) scores over a 1 year period were assessed for all patients. Patients were placed into 1 of 3 study groups, those that improved by 10 points, those that worsened by 10 points, and those that did not change (score change less than 10 points in either direction). Movement between study groups, the minimal clinical important difference (MCID), and patient satisfaction were analyzed for each patient.

Results

Improvement between preoperative and the 3 month postoperative evaluations was noted for most patients. There was limited change in scores after 3 months. Patients in the improved group continued to improve through 1 year postoperative. Patients in the worsened group continued to decline by 1 year postoperative. Patients in the no change group demonstrated the highest potential to change groups.

Conclusions

Patients with substantial improvement or worsening at 3 months have a low likelihood of substantial clinical change thereafter. This subset of patients may not need further evaluation with PROs, but those in the worsened group may benefit from other interventions to potentially alter their course.

The potential role of synthetic computed tomography in spinal surgery: generation, applications, and implications for future clinical practice

Computed tomography (CT) is widely used for the diagnosis and surgical treatment of spinal pathologies, particularly for pedicle screw placement. However, CT's limitations, notably radiation exposure, necessitate the development of alternative imaging techniques. Synthetic CT (sCT), which generates CT-like images from existing magnetic resonance imaging (MRI) scans, offers a promising alternative to reduce radiation exposure. This study examines the emerging role of sCT in spinal surgery, focusing on usability, efficiency, and potential impact on surgical outcomes. This qualitative literature review evaluated various sCT generation methods, encompassing traditional atlas-based and bulk-density models, as well as advanced convolutional neural network (CNN) architectures, including U-net, V-net, and generative adversarial network models. The review assessed sCT accuracy and clinical feasibility across different medical disciplines, particularly oncology and surgery, with potential applications in orthopedic, neurosurgical, and spinal surgery. sCT has shown significant promise across various medical disciplines. CNN-based techniques enable rapid and accurate generation of sCT from MRI scans, rendering clinical use feasible. sCT has been used to identify pathologies and monitor disease progression, suggesting that MRI alone may suffice for diagnosis and planning in the future. In spinal surgery, sCTs are particularly useful in visualizing key anatomical features like vertebral dimensions and spinal canal diameter. However, challenges persist, especially in visualizing complex structures and larger spinal regions, like the lumbar spine. Additional limitations include inaccuracies stemming from surgical implants and image variability. The application of sCT technology in spinal surgery holds great promise, improving diagnostics, planning, and treatment outcomes. Although further research is required to improve its precision, it offers a viable alternative to traditional CT in many clinical contexts, with the potential for broader application as the technology matures.

Risk factors of acute urinary retention after spine surgery

Acute postoperative urinary retention (APOUR) is 1 of the most common complications of spinal surgery, impacting both postoperative care and the patients' quality of life. This study is designed to investigate the risk factors and the incidence of APOUR after spinal surgery in Taiwan. We conducted a retrospective analysis using the Taiwanese National Health Insurance Research Database (NHIRD), a nationwide cohort of patients who underwent spinal surgery from the year 2000 to 2013. Patients suffering from APOUR were collected and perioperative parameters were recorded. The risk factors related to APOUR after spinal surgery were examined using multivariate logistic regression analysis. A total of 16,160 patients who underwent spinal surgery were retrieved from NHIRD. Among them, 432 (2.67%) suffered from acute urinary retention after surgery. Multivariate logistic regression analysis revealed that age (adjusted odds ratio [OR] = 1.02, 95% CI = 1.01-1.02), male gender (adjusted OR = 1.35, 95% CI = 1.10-1.60) and undergoing spinal surgery more than 2 times (adjusted OR = 4.78, 95% CI = 2.49-9.20) were statistically significant risk factors for APOUR after spinal surgery. The results of this retrospective cohort study suggest that patients undergoing spinal surgery more than 2 times, male gender and advanced age are significantly associated with an increased risk of APOUR after spinal surgery. This information may assist surgeons to identify patients who have a high risk of APOUR after spinal surgery and proactively provide them with early intervention.

Spinal navigation with AI-driven 3D-reconstruction of fluoroscopy images: an ex-vivo feasibility study

BACKGROUND

With the increasing number of surgeries utilizing spinal instrumentation, three-dimensional surgical navigation aims to improve the accuracy of implant placement. However, its widespread clinical adaption has been hindered by factors such as high radiation exposure and interference with standard surgical workflows.

METHODS

X23D is a novel AI-based fluoroscopy reconstruction technique that generates a 3D anatomical model of the spine from only four fluoroscopy images. Based on this technology, we developed a prototype for the surgical navigation of pedicle screws placement of the lumbar spine, visualizing the 3D-reconstructed spine anatomy and the surgical drill position in real-time. An ex-vivo study was conducted to compare the accuracy of the X23D-based navigation approach with fluoroscopy-aided freehand instrumentation. Five board-certified surgeons placed pedicle screws on six human torsi within a realistic surgical environment. Breach rate, site and extent (Gertzbein-Robbins) were evaluated in postoperative CT scans, as well as execution time, radiation dose, and user experience. Specimens, operating side, and surgeon were randomised.

RESULTS

Forty-nine pedicle screws (n = 24 × 23D, n = 25 2D-fluoroscopy) were evaluated, with six breaches occurring in the control group, one of which was considered clinically significant (medial breach grade C). Five breaches with one clinically significant breach were observed in the X23D group. Breach rate, execution time for each lumbar level (X23D 167 s vs. control 156 s), radiation dose (X23D 33.26 mGy vs. control 49.5 mGy), and user experience did not reveal significant differences (p > 0.05) between the groups.

CONCLUSIONS

Spinal navigation using the X23D-based approach shows promise and performs well in a realistic surgical ex-vivo setting. With further refinements, its accuracy is expected to match clinical-grade navigation systems while reducing radiation dose.

Fusion versus decompression alone for lumbar degenerative spondylolisthesis and spinal stenosis: a target trial emulation with index trial benchmarking

PURPOSE

The value of adding fusion to decompression surgery for lumbar degenerative spondylolisthesis and spinal canal stenosis remains debated. Therefore, the comparative effectiveness and selected healthcare resource utilization of patients undergoing decompression with or without fusion surgery at 3 years follow-up was assessed.

METHODS

Using observational data from the Lumbar Stenosis Outcome Study and a target trial emulation with index trial benchmarking approach, our study assessed the comparative effectiveness of the two main surgical interventions for lumbar degenerative spondylolisthesis-fusion and decompression alone in patients with lumbar degenerative spondylolisthesis and spinal canal stenosis. The primary outcome-measure was change in health-related quality of life (EuroQol Health Related Quality of Life 5-Dimension 3-Level questionnaire [EQ-5D-3L]); secondary outcome measures were change in back/leg pain intensity (Numeric Rating Scale), change in satisfaction (Spinal Stenosis Measure satisfaction subscale), physical therapy and oral analgesic use (healthcare utilization).

RESULTS

153 patients underwent decompression alone and 62 had decompression plus fusion. After inverse probability weighting, 137 patients were included in the decompression alone group (mean age, 73.9 [7.5] years; 77 female [56%]) and 36 in the decompression plus fusion group (mean age, 70.1 [6.7] years; 18 female [50%]). Our findings were compatible with no standardized mean differences in EQ-5D-3L summary index change score at 3 years (EQ-5D-3L German: 0.07 [95% confidence interval (CI), - 0.25 to 0.39]; EQ-5D-3L French: 0.18 [95% CI, - 0.14 to 0.50]). No between-group differences in change in back/leg pain intensity or satisfaction were found. Decompression plus fusion was associated with greater physical therapy utilization at 3 years follow-up.

CONCLUSION

Decompression alone should be considered the primary option for patients with lumbar degenerative spondylolisthesis and spinal stenosis.

Comparing opioid utilization and costs for surgical management of single-level spondylolisthesis: A national claims database analysis

Introduction

The rise in degenerative lumbar spondylolisthesis (DLS) cases has led to a significant increase in fusion surgeries, which incur substantial hospitalization costs and often necessitate chronic opioid use for pain management. Recent evidence suggests that single-level low-grade DLS outcomes are comparable whether a fusion procedure or decompression alone is performed, sparking debate over the cost-effectiveness of these procedures, particularly with the advent of minimally invasive techniques reducing the morbidity of fusion. This study aims to compare chronic opioid utilization and associated costs between decompression alone and decompression with instrumented fusion for single-level degenerative lumbar spondylolisthesis.

Material and methods

Using data from the PearlDiver database, a retrospective database analysis was conducted. We analyzed records of Medicare and Medicaid patients undergoing lumbar fusion or decompression from 2010 to 2022. Patient cohorts were divided into decompression alone (DA) and decompression with instrumented fusion (DIF). Chronic opioid use, pain clinic visits, and total costs were compared between the two groups at 90 days, 1 year, and 2 years post-surgery.

Theory

Does DIF offer a more cost-effective approach to managing DLS in terms of chronic opioid use in single-level DLS patients.

Results

The study revealed comparable chronic opioid use and pain clinic visits between DA and DIF groups at 90 days and 1 year. However, total costs associated with opioid prescriptions as well as surgical aftercare were significantly higher in the DIF group at 90 days (p < 0.05), 1 year (p < 0.05), and 2 years (p < 0.05) post-surgery compared to the DA group.

Conclusions

This study highlights the higher costs associated with DIF up to 2 years post-surgery despite comparable symptom improvement when compared to DA and DIF at the 1-year interval. DA emerges as a more financially favorable option, challenging the notion of fusion's cost-offsetting benefits. While further investigation is needed to understand underlying cost drivers and optimize outcomes, our findings emphasize the necessity of integrating clinical and economic factors in the management of single-level DLS.

Educating residents in spine surgery: A study of Entrustable professional activities in neurosurgery and orthopedic surgery

BACKGROUND

Surgery for spinal disorders represents some of the commonest surgical procedures performed in many countries worldwide, carried out by neurosurgeons and orthopedic surgeons. Residency training is shifting to competency-based medical education, which requires setting standards for graduating residents and their assessments. However, gaps exist in the literature regarding the parameters used for assessment and the mastery levels expected of graduating residents in the performance of common spinal procedures as defined in Entrustable Professional Activities (EPAs). The objectives of the study were to describe the assessment parameters used for residents, identify the standard of performance expected of graduating residents of EPAs of spinal procedures, and identify factors predicting the expected standard of competent performance of graduating residents.

METHODS

The survey was sent to neurosurgery and orthopedic surgery Faculty requesting their recommendations on parameters of assessment and the expected standard competence performance for EPAs related to spinal procedures using our entrustment scale (A-E).

RESULTS

Based on total responses, the recommended number of assessments and assessors for each EPA was 5 and 2, respectively. Regarding each specialty, there was no significant difference in the recommended number of assessments for each EPA. However, neurosurgery Faculty recommended higher number of assessors(n = 3) than orthopedic surgery Faculty(n = 2) for both posterior spinal decompression EPA(PSD) (p = 0.01) and spinal instrumentation EPA(SI) (p = 0.04). Based on total responses, 83% felt PSD was appropriate to the general practice, 86.8% considered it not too broad, and 62.3% expected entrustment level E as a graduation target. The proportions of these ratings were slightly lower for SI at 58.5%, 71.7% and 56.6%, respectively. Both specialties indicated that the EPAs were not too broad. In contrast, neurosurgery Faculty were more likely to consider these EPAs appropriate for general practice than orthopedic surgery Faculty for both PSD (94.7% vs 53.3%, p = 0.0003) and SI (68.4% vs 33.3%, p = 0.02). Moreover, neurosurgery Faculty had a higher expected standard of performance as a graduation target for both PSD (Level E 76.3% vs 26.7%, p = 0.001) and SI (Level E 65.8% vs 33.3%, p = 0.03) than orthopedic surgery Faculty. Expectations of entrustment level E for PSD was associated with the belief that the current EPA was appropriate for the general practice of their specialty with an odds ratio of 8.35 (p = 0.01, 95%CI 1.53-45.67).

CONCLUSIONS

A difference exists in parameters of assessment and expected standard competence performance of spine procedures among spinal surgery specialties. In our opinion, there should be efforts to develop consensus between specialties for the sake of uniform delivery of high-quality care for patients regardless of the specialty of their surgeon. Our results will be particularly valuable to certification bodies in the assessment of spinal milestones. This study has important implications for the design of residency and fellowship education in spinal surgery internationally.

Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

Objectives

Comprehensive preoperative management involves the identification and optimization of medical comorbidities while avoiding excessive healthcare utilization. While diabetes and heart disease are major causes of morbidity that can worsen surgical outcomes, further study is needed to evaluate how well current perioperative strategies mitigate their risks. This study employs an exact matching protocol to isolate the effects of both diabetes and cardiovascular disease on spine surgery outcomes.

Methods

4680 consecutive patients undergoing single-level, posterior-only lumbar fusion were retrospectively enrolled. Univariate logistic regression was performed on comorbidity subgroups, then coarsened exact matching (CEM) was employed for patients with diabetes or cardiovascular disease. Patients were matched 1:1 on ten patient and procedural characteristics known to affect neurosurgical outcomes. Separate pairs of exact-matched cohorts were generated to isolate both cardiovascular disease (matched n = 192), and diabetes (matched n = 380). Primary outcomes were surgical complications; length of stay; discharge disposition (home vs. non-home); and 30- and 90-day Emergency Department (ED) visits, readmissions, reoperations, and mortality.

Results

Cardiovascular disease and diabetes subgroups were not associated with short term outcomes after matching to control for confounders. Compared to univariate statistics, this method demonstrates that confounding control variables may drive outcomes more than these comorbidities themselves.

Conclusion

Between otherwise exactly matched patients undergoing lumbar fusion, diabetes and cardiovascular disease posed no greater risk of short-term adverse outcomes. This suggests proper selection criteria for surgical candidates and effective current perioperative strategies to mitigate these common comorbidities. Further studies are warranted to assess and optimize the cost-effectiveness of preoperative management for patients with common comorbidities.

Injectable bioactive poly(propylene fumarate) and polycaprolactone based click chemistry bone cement for spinal fusion in rabbits

Degenerative spinal pathology is a widespread medical issue, and spine fusion surgeries are frequently performed. In this study, we fabricated an injectable bioactive click chemistry polymer cement for use in spinal fusion and bone regrowth. Taking advantages of the bioorthogonal click reaction, this cement can be crosslinked by itself eliminating the addition of a toxic initiator or catalyst, nor any external energy sources like UV light or heat. Furthermore, nano-hydroxyapatite (nHA) and microspheres carrying recombinant human bone morphogenetic protein-2 (rhBMP-2) and recombinant human vascular endothelial growth factor (rhVEGF) were used to make the cement bioactive for vascular induction and osteointegration. After implantation into a rabbit posterolateral spinal fusion (PLF) model, the cement showed excellent induction of new bone formation and bridging bone, achieving results comparable to autograft control. This is largely due to the osteogenic properties of nano-hydroxyapatite (nHA) and the released rhBMP-2 and rhVEGF growth factors. Since the availability of autograft sources is limited in clinical settings, this injectable bioactive click chemistry cement may be a promising alternative for spine fusion applications in addressing various spinal conditions.

Does Epidural Corticosteroid Application During Spinal Surgery Reduce Postoperative Pain?: An Adjunct to Multimodal Analgesia

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blinded study.

OBJECTIVE

To examine the effect of intraoperative epidural administration of Depo-Medrol on postoperative back pain and radiculitis symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF).

SUMMARY OF BACKGROUND DATA

Postoperative pain is commonly experienced by patients undergoing spinal fusion surgery. Adequate management of intense pain is necessary to encourage early ambulation, increase patient satisfaction, and limit opioid consumption. Intraoperative steroid application has been shown to improve postoperative pain in patients undergoing lumbar decompression surgeries. There have been no studies examining the effect of epidural steroids on both back pain and radicular pain in patients undergoing TLIF.

METHOD

In all, 151 patients underwent TLIF surgery using rh-BMP2 with 3 surgeons at a single institution. Of those, 116 remained in the study and were included in the final analysis. Based on a 1:1 randomization, a collagen sponge saturated with either Saline (1 cc) or Depo-Medrol (40 mg/1 cc) was placed at the annulotomy site on the TLIF level. Follow-up occurred on postoperative days 1, 2, 3, 7, and postoperative months 1, 2, and 3. Lumbar radiculopathy was measured by a modified symptom- and laterality-specific Visual Analog Scale (VAS) regarding the severity of back pain and common radiculopathy symptoms.

RESULTS

The patients who received Depo-Medrol, compared with those who received saline, experienced significantly less back pain on postoperative days 1, 2, 3, and 7 ( P <0.05). There was no significant difference in back pain beyond day 7. Radiculopathy-related symptoms such as leg pain, numbness, tingling, stiffness, and weakness tended to be reduced in the steroid group at most time points.

CONCLUSION

This study provides Level 1 evidence that intraoperative application of Depo-Medrol during a TLIF surgery with rh-BMP2 significantly reduces back pain for the first week after TLIF surgery. The use of epidural Depo-Medrol may be a useful adjunct to multimodal analgesia for pain relief in the postoperative period.

Advances in implants and bone graft types for lumbar spinal fusion surgery

The increasing prevalence of spinal disorders worldwide necessitates advanced treatments, particularly interbody fusion for severe cases that are unresponsive to non-surgical interventions. This procedure, especially 360° lumbar interbody fusion, employs an interbody cage, pedicle screw-and-rod instrumentation, and autologous bone graft (ABG) to enhance spinal stability and promote fusion. Despite significant advancements, a persistent 10% incidence of non-union continues to result in compromised patient outcomes and escalated healthcare costs. Innovations in lumbar stabilisation seek to mimic the properties of natural bone, with evolving implant materials like titanium (Ti) and polyetheretherketone (PEEK) and their composites offering new prospects. Additionally, biomimetic cages featuring precisely engineered porosities and interconnectivity have gained traction, as they enhance osteogenic differentiation, support osteogenesis, and alleviate stress-shielding. However, the limitations of ABG, such as harvesting morbidities and limited fusion capacity, have spurred the exploration of sophisticated solutions involving advanced bone graft substitutes. Currently, demineralised bone matrix and ceramics are in clinical use, forming the basis for future investigations into novel bone graft substitutes. Bioglass, a promising newcomer, is under investigation despite its observed rapid absorption and the potential for foreign body reactions in preclinical studies. Its clinical applicability remains under scrutiny, with ongoing research addressing challenges related to burst release and appropriate dosing. Conversely, the well-documented favourable osteogenic potential of growth factors remains encouraging, with current efforts focused on modulating their release dynamics to minimise complications. In this evidence-based narrative review, we provide a comprehensive overview of the evolving landscape of non-degradable spinal implants and bone graft substitutes, emphasising their applications in lumbar spinal fusion surgery. We highlight the necessity for continued research to improve clinical outcomes and enhance patient well-being.

Return to Work Following Anterior Lumbar Interbody Fusion with Percutaneous Posterior Pedicle Fixation: A Retrospective Analysis from Two Academic Centers in Germany

Objective: Return to work after spinal surgery is a crucial factor in the recovery process. It can contribute not only to physical rehabilitation but also to psychological well-being. This study aims to evaluate the rate of return to work following elective lumbar spine surgery and identify predictors that predict failure of return to work. Methods: Adult patients who underwent anterior lumbar interbody fusion at two medical centers were retrospectively identified. A standardized telephone interview was conducted for the final analysis to assess the clinical outcomes of these patients. Results: Out of a total of 159 patients, 104 were of working age at the time of the elective surgery. Data were missing for 35 patients, who were thus excluded from the analysis. All patients had a minimum follow-up period of one year. After surgery, 75% of the patients returned to work within a median time of 3 months. Quality of life, back pain, leg pain, and ODI scores, as well as self-reported satisfaction, were significantly better in patients who returned to work (p < 0.05). Tobacco use and previous musculoskeletal surgery were significant predictive factors of failure to return to work. None of the patients who were unemployed prior to surgery returned to work. Conclusions: Our study reveals that 75% of patients returned to work within three months after surgery. The most significant predictor of failure to return to work is being unemployed before surgery. Additionally, preoperative education about postoperative behavior and physical activity could potentially increase the rate.

The Implementation of Enhanced Recovery After Spine Surgery in High and Low/Middle-income Countries: A Systematic Review and Meta-Analysis

In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (-2.06; 95% CI, -2.47 to -1.64 d) and HIC (-0.99; 95% CI, -1.28 to -0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.

Basivertebral nerve ablation technique

Chronic low back pain represents a leading cause of global disability, but can often be complex in etiology, with multiple pain generators contributing to patient discomfort. Anterior column low back pain involves the vertebral bodies and discs, with the vertebral body endplates now known to be a significant pain generator. Vertebrogenic low back pain secondary to irritation of the basivertebral nerve presents as axial discomfort, worse with forward flexion, and with concomitant Type I or II Modic changes on MRI. Minimally invasive basivertebral nerve radiofrequency ablation has emerged as an effective intervention for managing anterior column back pain. In this article, the authors present a comprehensive approach to identifying and treating vertebrogenic low back pain through image guided basivertebral nerve ablation. We outline the patient presentation and diagnostic workup, followed by a detailed procedural guide including equipment requirements, technique execution, and potential technical challenges and complications.

Outcomes following spinal instrumented fusions in patients with parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Parkinson's Disease (PD) patients represent challenging spinal surgery candidates due to associated frailty and deformity. This study consolidates the literature concerning spinal surgery outcomes in PD versus non-PD patients, to evaluate if PD predisposes patients to worse post-operative outcomes, so that treatment protocols can be optimised.

METHODS

A systematic review and meta-analysis was conducted of PubMed/Medline, Embase, and Google Scholar databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies of interest included comparative (PD versus non-PD) cohorts undergoing spinal instrumented fusions. Post-operative clinical outcomes were collated and compared for significance between cohorts. Further analysis was made on outcomes based on the different surgical procedures performed (Anterior Cervical Discectomy and Fusion (ACDF), Thoracolumbar or Lumbar fusions, Thoracolumbar or Lumbar fusions without Osteoporotic Vertebral Compression fracture (OVCF) patients). All statistical analysis was performed using The R Project for Statistical Computing (version 4.1.2), with a p-value of < 0.05 deemed statistically significant.

RESULTS

In total, 2,323,650 patients were included across 16 studies. Of those, 2,308,949 (99.37%) were patients without PD (non-PD), while 14,701 (0.63%) patients had PD at time of surgery. The collective mean age was 68.23 years (PD: 70.14 years vs non-PD: 64.86 years). Comparatively, there were 844,641 males (PD: 4,574; non-PD: 840,067) and 959,908 females (PD: 3,213; non-PD: 956,695). Overall, there were more post-operative complications in the PD cohort. Specifically, PD patients experienced significantly more surgical site infections (p = 0.01), increased rates of revision surgeries (p = 0.04) and increased venous thromboembolic events (p = 0.02) versus the non-PD cohort. In thoracolumbar/lumbar spinal fusions without OVCF patients, the PD cohort had increased rates of revision surgeries (p < 0.01) in comparison to the non-PD cohort. However, when including OVCF patients in thoracolumbar/lumbar spinal fusions, the PD cohort had significantly higher amounts of postoperative complications (p = 0.01), pneumonia (p = 0.02), and revision surgeries (p < 0.01) when compared to the non-PD cohort.

CONCLUSION

Although more robust prospective studies are needed, the results of this study highlight the need for advanced wound care management in the postoperative period, both in-hospital and in the community, in addition to comprehensive multidisciplinary care from allied health professionals, with potential for the use of Enhanced Recovery After Surgery (ERAS) protocols in PD patients undergoing spinal instrumented fusions.

Quantifying value loss due to presenteeism and absenteeism in workers' compensation spinal patients

Background

Recent studies suggest that better outcomes in work productivity following spine surgery eventually offset the higher cost of treatment. By analyzing preoperative and postoperative changes in work productivity, studies can determine if surgery is cost-effective and give patients valuable information about treatment. Prior studies reviewing outcomes in work performance after spine surgery have largely excluded patients on workers' compensation from the overall cost analysis.

Methods

A retrospective review of 92 eligible patients was conducted. Evaluation of the EHR identified presenteeism and absenteeism from designated work restrictions. Statistical analyses were conducted using JMP Pro 17.

Results

About 84 (83%) spinal surgery cases were able to return to work, 60 (59%) were able to return to work with no restrictions, 26 (26%) received permanent work restrictions, and 12 (12%) were still undergoing treatment. 86 (85%) experienced presenteeism and 99 (98%) experienced absenteeism. Of the cases that were able to return to work without permanent work restrictions, the mean presenteeism length postoperatively was 287.4 days (median 191 days) and the mean absenteeism length postoperatively was 232.5 days (median 142 days). 72 patients were identified as having sedentary or nonsedentary labor. After excluding outliers, the average return-to-work length was 988.62 days for patients with sedentary employment types and 952.15 days for patients with nonsedentary employment types (p=.116).

Conclusion

Following spinal surgery, our worker's compensation patient population's return-to-work rate was at an average of 232.5 days (median of 142 days) for 83% of patients included in this study. This exhibited worse outcomes than a previous study's measurement excluding worker's compensation patients. Presenteeism length within our population contributed more to decreased work productivity postoperatively than absenteeism length. Our results found no significant difference in return-to-work length between patients with sedentary and nonsedentary employment types.

Physical Therapy Utilization After Single-level Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Characterize physical therapy (PT) utilization following single-level posterior lumbar fusion (PLF).

SUMMARY OF BACKGROUND DATA

PLF is a common procedure that is increasing in frequency. After such surgeries, PT may be considered to facilitate mobilization and return to activities. However, the usage of such therapy has not been well-characterized in the literature.

MATERIALS AND METHODS

Patients undergoing single-level PLF were identified from the 2010 to 2021 PearlDiver administrative database. These patients were stratified based on usage of therapy, home versus outpatient therapy, and timing of therapy within the year after surgery. To determine predictors of therapy, patient characteristics were determined and multivariable regressions were performed.

RESULTS

A total of 213,240 patients undergoing single-level PLF were identified, of which therapy was done in the year after surgery for 63,231 (29.0%, of which home therapy accounted for 16.5% of therapy visits). Of those who utilized PT, the average number of visits was 10.6±10.6. Home therapy peaked within the first month after surgery and outpatient therapy peaked at month two. Factors associated with any PT following PLF in decreasing odds ratio (OR) were having commercial insurance (OR: 1.68), being from the Northeast (OR: 1.41), age (OR: 1.13 for 70+ of age) female sex (OR: 1.09), and ECI (OR: 1.04 per point) ( P <0.001 for all). Of those who received therapy, factors associated with home PT utilization were being from the Northeast (OR: 2.55), age (OR: 1.91 for 70+ of age), Medicaid insurance (OR: 1.48), female sex (OR: 1.39), and interbody fusion (OR:1.07) ( P <0.001 for all).

CONCLUSIONS

After single-level PLF, the minority of patients received home or outpatient PT. Of those who did, there was significant variation in the number of visits, with nonmedical factors such as insurance plan and geographic region being strongly associated suggesting room for more consistent practice patterns.

LEVEL OF EVIDENCE

Level 3.

Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis

BACKGROUND CONTEXT

As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion.

PURPOSE

To determine the variation of total hospital cost, differences in characteristics between high-cost and nonhigh-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion.

STUDY DESIGN/SETTING

Retrospective, multicenter (one academic medical center, one community-based hospital), observational study.

PATIENT SAMPLE

A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022.

OUTCOME MEASURES

Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion.

METHODS

Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and nonhigh-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost.

RESULTS

The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs 63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (ie, incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05).

CONCLUSIONS

A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (eg, implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.

The effect of chronic kidney disease on short-term single-level lumbar fusion outcomes

INTRODUCTION

Chronic kidney disease (CKD) has an increasing global prevalence and has previously been associated with increased complications and morbidity after spine surgery. Understanding the isolated effect of CKD on short-term patient outcomes is critical for optimizing perioperative risk management and healthcare utilization.

OBJECTIVE

The aim of this study is to utilize coarsened exact matching (CEM) to analyze the isolated effect of CKD on short-term patient outcomes in single-level posterior lumbar fusion surgery.

METHODS

A retrospective analysis of 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion was performed. Univariate logistic regression comparing the odds of outcomes in patients with CKD (n=40) to patients without medical comorbidities (n=2329) was performed. CEM was then employed to match patients with CKD to those without any comorbidities 1:1 on ten patient characteristics known to affect neurosurgical outcomes. Primary outcomes included intraoperative complications, length of stay, discharge disposition, and 30-day Emergency Department (ED) visits, readmissions, reoperations, and mortality.

RESULTS

In a univariate logistic regression, CKD was associated with increased risk of 30-day ED visits (OR=3.53, p=0.003) but not complication, discharge disposition, or 30-day readmissions or reoperations. Between otherwise exactly matched patients (n=72), CKD similarly remained associated with an increased risk of 30-day ED visits (OR=7.00, p=0.034) and not with other outcomes.

CONCLUSION

Between otherwise exactly matched patients undergoing single-level posterior lumbar fusion, CKD was related to increased risk of 30-day ED utilization but not other markers indicative of inferior surgical outcomes. Further study must investigate the reasons for increased ED visitation and implement risk-mitigation strategies for these patients.

Prevalence of total joint arthroplasty in the adult spine deformity population

PURPOSE

The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution.

METHODS

Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed.

RESULTS

572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%).

CONCLUSIONS

This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.

Relationship between number of prior lumbar spine surgeries and outcomes following spinal cord stimulator implantation: A multisite, retrospective pooled analysis

OBJECTIVES

Lumbar spine surgery is a common procedure for treating disabling spine-related pain. In recent decades, both the number and cost of spine surgeries have increased despite technological advances and modification in surgical technique. For those patients that have continued uncontrolled back and/or lower extremity pain following lumbar spine surgery, spinal cord stimulation (SCS) has emerged as a viable treatment option. However, the impact of lumbar spine surgical history remains largely unstudied. Specifically, the current study considers the impact of number of prior lumbar spine surgeries on pain relief outcomes following SCS implantation.

MATERIALS AND METHODS

We queried the electronic medical record of five separate pain practices for all patients who have undergone a SCS implant between January 1, 2017, and March 1, 2020. Inclusion criteria consisted of any patients with an SCS implant who underwent a prior lumbar spine surgery. The primary outcome was the mean calculated percentage pain relief in patients based on number of prior lumbar spine surgeries.

RESULTS

There was a total of 1974 total SCS implant cases identified across five separate pain clinics. There was no difference in mean calculated pain relief in patients with one prior spine surgery versus those with two or more prior spine surgeries (28.2% vs. 25.8%, adjusted β-coefficient -3.1, 95% CI -8.9 to 2.7, p = 0.290). Similarly, when analyzing number of spine surgeries as a continuous variable, there was no association between number of spine surgeries and calculated pain relief (adjusted β-coefficient -1.5, 95% CI -4.0 to 1.1, p = 0.257). Additionally, after patients were stratified based on waveform, there was no association between number of prior lumbar spine surgeries (analyzed both as a categorical and continuous variable) and calculated percentage pain relief.

CONCLUSIONS

This multicentered retrospective study found that there was no significant difference in pain scores in individuals who received SCS following one or more lumbar spine surgeries. Additionally, the waveform of the SCS device had no statistically significant impact on post-operative pain scores following one or more lumbar spine surgeries.

Decompression alone or with fusion for degenerative lumbar spondylolisthesis (Nordsten-DS): five year follow-up of a randomised, multicentre, non-inferiority trial

OBJECTIVE

To assess whether decompression alone is non-inferior to decompression with instrumented fusion five years after primary surgery in patients with degenerative lumbar spondylolisthesis.

DESIGN

Five year follow-up of a randomised, multicentre, non-inferiority trial (Nordsten-DS).

SETTING

16 public orthopaedic and neurosurgical clinics in Norway.

PARTICIPANTS

Patients aged 18-80 years with symptomatic lumbar spinal stenosis and a spondylolisthesis of 3 mm or more at the stenotic level.

INTERVENTIONS

Decompression surgery alone and decompression with additional instrumented fusion (1:1).

MAIN OUTCOME MEASURES

The primary outcome was a 30% or more reduction in Oswestry disability index from baseline to five year follow-up. The predefined non-inferiority margin was a -15 percentage point difference in the proportion of patients who met the primary outcome. Secondary outcomes included the mean change in Oswestry disability index, Zurich claudication questionnaire, numeric rating scale for leg and back pain, and EuroQol Group 5-Dimension (EQ-5D-3L) questionnaire.

RESULTS

From 12 February 2014 to 18 December 2017, 267 participants were randomly assigned to decompression alone (n=134) and decompression with instrumented fusion (n=133). Of these, 230 (88%) responded to the five year questionnaire: 121 in the decompression group and 109 in the fusion group. Mean age at baseline was 66.2 years (SD 7.6), and 69% were women. In the modified intention-to-treat analysis with multiple imputation of missing data, 84 (63%) of 133 people in the decompression alone group and 81 (63%) of 129 people in the fusion group had a at least a 30% reduction in Oswestry disability index, a difference of 0.4 percentage points. (95% confidence interval (CI) -11.2 to 11.9). The respective results of the per protocol analysis were 65 (65%) of 100 in the decompression alone group and 59 (66%) of 89 in the fusion group, a difference of -1.3 percentage points (95% CI -14.5 to 12.2). Both 95% CIs were higher than the predefined non-inferiority margin of -15%. The mean change in Oswestry disability index from baseline to five years was -17.8 in both groups (mean difference 0.02 (95% CI -3.8 to 3.9)). Results of the other secondary outcomes were in the same direction as the primary outcome. From two to five year follow-up, a new lumbar operation occurred in six (5%) of 123 people in the decompression group and 11 (10%) of 113 people in the fusion group, with a total from baseline to five years of 21 (16%) of 129 people and 23 (18%) of 125, respectively.

CONCLUSIONS

In participants with degenerative spondylolisthesis, decompression alone was non-inferior to decompression with instrumented fusion five years after primary surgery. Proportions of subsequent surgeries at the index level or an adjacent lumbar level were no different between the groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02051374.

Long-Term Follow-Up of a Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion

OBJECTIVE

Long-term follow-ups of prehabilitation programs for lumbar spine surgery are lacking, and more comprehensive evaluations are needed. In the current study, we evaluated the long-term effects of a prehabilitation program compared with conventional care in relation to lumbar fusion surgery in patients with degenerative disc disease.

METHODS

Patients (n = 118) receiving lumbar fusion surgery were included in a multicenter randomized controlled trial, involving 1 university hospital and 2 spine clinics. The intervention was a person-centered prehabilitation program based on cognitive-behavioral physical therapy that targeted psychological presurgical risk factors, physical activity, and overall health. The control group received conventional preoperative care. Patient-reported outcome measures (PROMs) included assessments at 8 time-points: low back disability (primary outcome), back pain intensity, leg pain intensity, pain catastrophizing, fear of movement, anxiety and depressive mood, health-related quality of life, and patient-specific functioning. Physical activity and physical capacity were assessed at 5 time points. Linear mixed models were used to analyze the effects of the intervention.

RESULTS

There were no significant differences between groups at the 12- and 24-month follow-ups for any outcome, except for the One Leg Stand test 1 year following surgery, in favor of the control group. There were significant improvements for both groups, from baseline to the 12- and 24-month follow-ups for all physical capacity test and patient-reported outcome measures, except for leg pain and self-efficacy for exercise.

CONCLUSION

No long-term effects were found for the prehabilitation program compared to conventional care. Physical activity did not improve over time, despite significantly improved self-reported functioning and physical capacity measurements.

IMPACT

These findings have implications for the current understanding of the long-term effects of prehabilitation and suggest that future research should focus on programs promoting physical activity both before and after lumbar spine surgery to decrease the risk of long-term adverse health outcomes.

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: a prospective cohort study

BACKGROUND

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains.

MATERIALS AND METHODS

An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery.

RESULTS

A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery.

CONCLUSION

Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level

BACKGROUND/CONTEXT

Degenerative lumbar spondylolisthesis (DLS) is a prevalent spinal condition that can result in significant disability. DLS is thought to result from a combination of disc and facet joint degeneration, as well as various biological, biomechanical, and behavioral factors. One hypothesis is the progressive degeneration of segmental stabilizers, notably the paraspinal muscles, contributes to a vicious cycle of increasing slippage.

PURPOSE

To examine the correlation between paraspinal muscle status on MRI and severity of slippage in patients with symptomatic DLS.

STUDY DESIGN/SETTING

Retrospective cross-sectional study at an academic tertiary care center.

PATIENT SAMPLE

Patients who underwent surgery for DLS at the L4/5 level between 2016-2018 were included. Those with multilevel DLS or insufficient imaging were excluded.

OUTCOME MEASURES

The percentage of relative slippage (RS) at the L4/5 level evaluated on standing lateral radiographs. Muscle morphology measurements including functional cross-sectional area (fCSA), body height normalized functional cross-sectional area (HI) of Psoas, erector spinae (ES) and multifidus muscle (MF) and fatty infiltration (FI) of ES and MF were measured on axial MR. Disc degeneration and facet joint arthritis were classified according to Pfirrmann and Weishaupt, respectively.

METHODS

Descriptive and comparative statistics, univariable and multivariable linear regression models were utilized to examine the associations between RS and muscle parameters, adjusting for confounders sex, age, BMI, segmental degeneration, and back pain severity and symptom duration.

RESULTS

The study analyzed 138 out of 183 patients screened for eligibility. The median age of all patients was 69.5 years (IQR 62 to 73), average BMI was 29.1 (SD±5.1) and average preoperative ODI was 46.4 (SD±16.3). Patients with Meyerding-Grade 2 (M2, N=25) exhibited higher Pfirrmann scores, lower MFfCSA and MFHI, and lower BMI, but significantly more fatty infiltration in the MF and ES muscles compared to those with Meyerding Grade 1 (M1). Univariable linear regression showed that each cm2 decrease in MFfCSA was associated with a 0.9%-point increase in RS (95% CI -1.4 to - 0.4, p<.001), and each cm2/m2 decrease in MFHI was associated with an increase in slippage by 2.2%-points (95% CI -3.7 to -0.7, p=.004). Each 1%-point rise in ESFI and MFFI corresponded to 0.17%- (95% CI 0.05-0.3, p=.01) and 0.20%-point (95% CI 0.1-0.3 p<.001) increases in relative slippage, respectively. Notably, after adjusting for confounders, each cm2 increase in PsoasfCSA and cm2/m2 in PsoasHI was associated with an increase in relative slippage by 0.3% (95% CI 0.1-0.6, p=.004) and 1.1%-points (95% CI 0.4-1.7, p=.001). While MFfCSA tended to be negatively associated with slippage, this did not reach statistical significance (p=.105). However, each 1%-point increase in MFFI and ESFI corresponded to increases of 0.15% points (95% CI 0.05-0.24, p=.002) and 0.14% points (95% CI 0.01-0.27, p=.03) in relative slippage, respectively.

CONCLUSION

This study found a significant association between paraspinal muscle status and severity of slippage in DLS. Whereas higher degeneration of the ES and MF correlate with a higher degree of slippage, the opposite was found for the psoas. These findings suggest that progressive muscular imbalance between posterior and anterior paraspinal muscles could contribute to the progression of slippage in DLS.

Vertebral Bone Quality Score as a Predictor of Adjacent Segment Disease After Lumbar Interbody Fusion

BACKGROUND AND OBJECTIVE

With lumbar spine fusion being one of the most commonly performed spinal surgeries, investigating common complications such as adjacent segment disease (ASD) is a high priority. To the authors' knowledge, there are no previous studies investigating the utility of the preoperative magnetic resonance imaging-based vertebral bone quality (VBQ) score in predicting radiographic and surgical ASD after lumbar spine fusion. We aimed to investigate the predictive factors for radiographic and surgical ASD, focusing on the predictive potential of the VBQ score.

METHODS

A single-center retrospective analysis was conducted of all patients who underwent 1-3 level lumbar or lumbosacral interbody fusion for lumbar spine degenerative disease between 2014 and 2021 with a minimum 12 months of clinical and radiographic follow-up. Demographic data were collected, along with patient medical, and surgical data. Preoperative MRI was assessed in the included patients using the VBQ scoring system to identify whether radiographic ASD or surgical ASD could be predicted.

RESULTS

A total of 417 patients were identified (mean age, 59.8 ± 12.4 years; women, 54.0%). Eighty-two (19.7%) patients developed radiographic ASD, and 58 (13.9%) developed surgical ASD. A higher VBQ score was a significant predictor of radiographic ASD in univariate analysis (2.4 ± 0.5 vs 3.3 ± 0.4; P < .001) and multivariate analysis (odds ratio, 1.601; 95% CI, 1.453-1.763; P < .001). For surgical ASD, a significantly higher VBQ score was seen in univariate analysis (2.3 ± 0.5 vs 3.3 ± 0.4; P < .001) and served as an independent risk factor in multivariate analysis (odds ratio, 1.509; 95% CI, 1.324-1.720; P < .001). We also identified preoperative disk bulge and preoperative existence of adjacent segment disk degeneration to be significant predictors of both radiographic and surgical ASD. Furthermore, 3-level fusion was also a significant predictor for surgical ASD.

CONCLUSION

The VBQ scoring system might be a useful adjunct for predicting radiographic and surgical ASD.

Transforaminal versus posterior lumbar interbody fusion for symptomatic single-level spondylolisthesis (LIFT): a multicentre controlled, patient blinded, randomised non-inferiority trial

Background

The effectiveness of transforaminal lumbar interbody fusion (TLIF) compared to posterior lumbar interbody fusion (PLIF) in patients with single-level spondylolisthesis has not been substantiated. To address the evidence gap, a well-powered randomized controlled non-inferiority trial comparing the effectiveness of TLIF with PLIF, entitled the Lumbar Interbody Fusion Trial (LIFT), was conducted.

Methods

In a multicenter randomized controlled non-inferiority trial among five Dutch hospitals, 161 patients were randomly allocated to either TLIF or PLIF (1:1), stratified according to study site. Patients and statisticians were blinded for group assignment. All patients were over 18 years old with symptomatic single-level degenerative, isthmic or iatrogenic lumbar spondylolisthesis, and eligible for lumbar interbody fusion surgery through a posterior approach. The primary outcome was change in disability measured with the Oswestry Disability Index (ODI) from preoperative to one year postoperative. The non-inferiority limit was set to 7.0 points based on the MCID of ODI. Secondary outcomes were change in quality-adjusted life years (QALY) assessed with EuroQol 5 Dimensions, 5 Levels (EQ-5D-5L) and Short Form Health Survey (SF-36), as well as back and leg pain (Numerical rating scale, NRS), anxiety and depression (Hospital Anxiety Depression Scale; HADS), perioperative blood loss, duration of surgery, duration of hospitalization, and complications. Trial registration: Netherlands Trial Registry, number 5722 (registration date March 30, 2016), Lumbar Interbody Fusion Trial (LIFT): A randomized controlled multicenter trial for surgical treatment of lumbar spondylolisthesis.

Findings

Patients were included between August 2017 and November 2020. The total study population was 161 patients. Total loss-to-follow-up after one year was 16 patients. Per-protocol analysis included 66 patients in each group. In the TLIF group (mean age 61.6, 36 females), ODI improved from 46.7 to 20.7, whereas in the PLIF group (mean age 61.9, 41 females), it improved from 46.0 to 24.9. This difference (-4.9, 90% CI -12.2 to +2.4) did not reach the non-inferiority limit of 7.0 points in ODI. A significant difference in the secondary outcome measurement, QALY (SF-36), was observed in favor of TLIF (P < 0.05). However, this was not clinically relevant. No difference was found for all other secondary outcome measurements; PROMs (EQ-5D, NRS leg/back, HADS), perioperative blood loss, duration of surgery, duration of hospitalization, and perioperative and postoperative complications.

Interpretation

For patients with single-level spondylolisthesis, TLIF is non-inferior to PLIF in terms of clinical effectiveness. Disability (measured with ODI) did not differ over time between groups.

Funding

No funding was received for this trial.

Lumbar fusion surgery in the era of an aging society: analysis of a nationwide population cohort with minimum 8-year follow-up

BACKGROUND CONTEXT

Fusions for lumbar spine diseases are widely performed and have a growing incidence, especially in elderly population.

PURPOSE

The goal of this study was to assess national trends of lumbar spinal fusions and examine the risk for reoperations after a lumbar fusion with a focus on 'epidemiologic transition' relating to age.

STUDY DESIGN/SETTING

The prospectively collected Korean Health Insurance Review and Assessment Service (HIRA) nationwide cohort database was retrospectively reviewed.

PATIENT SAMPLE

The total 278,815 patients who underwent lumbar spinal fusions for degenerative spine diseases between 2010 and 2018 were reviewed and used to assess trends in operative incidence. The 37,050 patients who underwent lumbar fusions between 1/2010 and 12/2011 were enrolled to determine 8-year reoperation rates.

OUTCOME MEASURES

The overall number of lumbar spinal fusions were analyzed for the national annual trend. Demographic data, reoperation rates, and confounding clinical factors were evaluated.

METHODS

The overall number of lumbar spinal fusions was analyzed to determine the national annual trend of operative incidence. For the reoperation rate analysis, the primary outcome measured was the cumulative incidence of revision operations within a minimum 8-year follow-up period. Additional outcomes included comparative analyses of the reoperation rate with respect to age, sex, or other underlying comorbidities.

RESULTS

Over time, elderly patients comprised a larger portion of the cohort (2010:24.2%; 2018:37.6%), while operations in younger patients decreased over time (2010:40.3%; 2018:27.0%). In the cohort of patients with a minimum 8-year follow-up (n=37,050), rates of reoperation peaked in patients aged 60-69 years (17.6 per 1000 person-years [HR 2.20 compared to <40years]) and decreased for more elderly patients (14.3 per 1000 person-years [HR 1.80 compared to <40years]). Age was the most significant risk factor for reoperation. Osteoporosis was also a risk factor for reoperation in postmenopausal females.

CONCLUSIONS

Increasing incidence of lumbar fusions in elderly patients was seen however the risk of reoperation decreased in patients aged 70 or more. Lumbar fusion for elderly patients should not be hesitated in the decision-making process because of concerns about reoperation.

Elevated Serum Alkaline Phosphatase is an Independent Predictor of Complications After Lumbar Spinal Fusion

BACKGROUND

Alkaline phosphatase (ALP) is an enzyme which has been proven useful as a biomarker for bone turnover and inflammation. We hypothesized that high serum ALP levels are associated with increased complication rates following lumbar spinal fusion.

METHODS

Lumbar spinal fusion procedures from 2005 to 2019 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Serum alkaline phosphatase levels were stratified into low <44 IU/L, normal 44-147 IU/L, and high >147 IU/L. A risk-adjusted multivariate logistic regression was used to analyze ALP as an independent risk factor for complications.

RESULTS

A total of 16,441 patients who underwent lumbar fusion procedures were included. Adjusted multivariate logistic regression analysis demonstrated that patients with a high serum ALP level had a significantly increased risk for developing septic shock (OR 4.68, 95% CI 1.83-11.97), pneumonia (OR 2.89, 95% CI 1.59-5.25), requiring a transfusion (OR 2.09, 95% CI 1.68-2.59), reoperation within 30 days (OR 1.68, 95% CI 1.12-2.52), readmission within 30 days (OR 1.60, 95% CI 1.16-2.21), increased length of stay (OR 1.87, 95% CI 1.49-2.36), and nonhome discharge (OR 2.18, 95% CI 1.80-2.66).

CONCLUSIONS

Elevated serum ALP in patients undergoing lumbar fusion procedures is associated with increased risk for multiple in-hospital complications as well as higher rates of readmission and reoperation.

What is the impact of DEI on spine care? Does it matter if my doctor looks like me?

Though the United States population has rapidly diversified in recent decades, the American physician workforce has been slow to follow. Orthopedic surgery and neurosurgery are 2 specialties which remain particularly homogenous, and the subset of orthopedic surgeons and neurosurgeons who pursue spine surgery is even less diverse, along many different demographic axes. To provide effective, innovative, and accessible care to the changing population, greater diversity in spine surgery is essential. This is achieved in part by recruitment, retention, and leadership sponsorship of a new generation of trainees and faculty who reflect the diversity of the patient population they will care for. For surgeons, workforce diversity means improved learning, innovation, and organizational performance. For patients, it means greater ability to access respectful, quality care. Investing in the future of spine surgery means creating a more diverse and inclusive field, 1 in which patients from all walks of life can say, "My doctor is different-like me."

Defining cage subsidence in anterior, oblique, and lateral lumbar spine fusion approaches: a systematic review of the literature

One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1%) reported on the ALIF approach, 22 (31.9%) on the OLIF approach, and 31 (44.9%) on the LLIF approach, 2 of which reported on more than one approach. ALIF articles most commonly calculated the loss of disc height over time with a subsidence threshold of > 2 mm. Most OLIF articles calculated the total amount of cage migration into the vertebral bodies, with a threshold of > 2 mm. LLIF was the only approach in which most articles applied the same method for calculation, namely, a grading scale for classifying the loss of disc height over time. We recommend future articles adhere to the most common methodologies presented here to ensure accuracy and generalizability in reporting cage subsidence.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion.

SUMMARY OF BACKGROUND DATA

As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery.

MATERIALS/METHODS

We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated.

RESULTS

A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75).

CONCLUSION

Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement.

LEVEL OF EVIDENCE

3.

The Categorization of Perinatal Derivatives for Orthopedic Applications

Musculoskeletal (MSK) pathology encompasses an array of conditions that can cause anything from mild discomfort to permanent injury. Their prevalence and impact on disability have sparked interest in more effective treatments, particularly within orthopedics. As a result, the human placenta has come into focus within regenerative medicine as a perinatal derivative (PnD). These biologics are sourced from components of the placenta, each possessing a unique composition of collagens, proteins, and factors believed to aid in healing and regeneration. This review aims to explore the current literature on PnD biologics and their potential benefits for treating various MSK pathologies. We delve into different types of PnDs and their healing effects on muscles, tendons, bones, cartilage, ligaments, and nerves. Our discussions highlight the crucial role of immune modulation in the healing process for each condition. PnDs have been observed to influence the balance between anti- and pro-inflammatory factors and, in some cases, act as biologic scaffolds for tissue growth. Additionally, we assess the range of PnDs available, while also addressing gaps in our understanding, particularly regarding biologic processing methods. Although certain PnD biologics have varying levels of support in orthopedic literature, further clinical investigations are necessary to fully evaluate their impact on human patients.

Spinal fusion surgery use among adults with low back pain enrolled in a digital musculoskeletal program: an observational study

OBJECTIVES

To compare 12-month spinal fusion surgery rates in the setting of low back pain among digital musculoskeletal (MSK) program participants versus a comparison cohort who only received usual care.

STUDY DESIGN

Retrospective cohort study with propensity score matched comparison cohort using commercial medical claims data representing over 100 million commercially insured lives.

METHODS

All study subjects experienced low back pain between January 2020 and December 2021. Digital MSK participants enrolled in the digital MSK low back program between January 2020 and December 2021. Non-participants had low back pain related physical therapy (PT) between January 2020 and December 2021. Digital MSK participants were matched to non-participants with similar demographics, comorbidities and baseline MSK-related medical care use. Spinal fusion surgery rates at 12 months post participation were compared.

RESULTS

Compared to non-participants, digital MSK participants had lower rates of spinal fusion surgery in the post-period (0.7% versus 1.6%; p < 0.001). Additionally, in the augmented inverse probability weighting (AIPW) model, digital MSK participants were found to have decreased odds of undergoing spinal fusion surgery (adjusted odds ratio: 0.64, 95% CI: 0.51-0.81).

CONCLUSIONS

This study provides evidence that participation in a digital MSK program is associated with a lower rate of spinal fusion surgery.

Implementing a nurse-led prehabilitation program for patients undergoing spinal surgery

ABSTRACT

Prehabilitation, or "prehab," helps patients optimize strength, function, and nutrition before surgery. This evidence-based practice project presents strategies for implementing a prehab program to prepare patients for spinal surgery. Nurses play an integral role in educating patients preoperatively about the myriad lifestyle changes associated with spinal surgery.

Trends in the surgical treatment for metastatic spinal tumor in Japanese administrative data between 2012 and 2020

BACKGROUND

Both cancer diagnosis/treatment modality and surgical technique for the spine have been developed recently. Nationwide trends in the surgical treatment for metastatic spinal tumors have not been reported in the last decades. This study aimed to examine recent trends in the surgical treatment for spinal metastasis and in-hospital patient outcomes using nationwide administrative hospital discharge data.

METHODS

The Diagnosis Procedure Combination database from 2012 to 2020 was used to extract data from patients who underwent surgical procedures for spinal metastasis with the number of non-metastatic spinal surgery at the institutions that have performed metastatic spine surgeries at least one case in the same year. Trends in the surgical treatment for spinal metastasis, patients' demographics, and in-hospital mortality/outcomes were investigated.

RESULTS

This study analyzed 10,321 eligible patients with spinal metastasis. The surgical treatment for spinal metastasis increased 1.68 times from 2012 to 2020, especially in fusion surgery, whereas the proportion of metastatic spinal surgery retained with a slight increase in the 2%s. Distributions of the primary site did not change, whereas age was getting older. In-hospital mortality and length of stay decreased over time (9.9-6.8%, p < 0.001; 37-30 days, p < 0.001). Postoperative complication and unfavorable ambulatory retained stable and slightly decreased, respectively.

CONCLUSION

During the last decade, surgical treatment for spinal metastasis, especially fusion surgery, has increased in Japan. In-hospital mortality and length of stay decreased. Recent advances in cancer treatment and surgical techniques might influence this trend.

Patient-level patterns in daily prescribed opioid dosage in single level lumbar fusion are associated with postoperative opioid dosage and adverse events: a retrospective analysis of claims data

BACKGROUND

Patients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively.

PURPOSE

Determine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events.

STUDY DESIGN/SETTING

Retrospective analysis of an administrative claims database (MeritiveTM Marketscan® Research Databases 2007-2015).

PATIENT SAMPLE

The 9,768 patients undergoing primary single level lumbar fusion.

OUTCOME MEASURES

Primary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition.

METHODS

Distinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors.

RESULTS

Among primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively: (1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day; (2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day; (3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day; (4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery; (5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery. These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High-dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain. Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0-5 MME/day, 29.1%), medium (10-15 MME/day, 12.0%), or high (70-75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids.

CONCLUSIONS

Identification of a patient's preoperative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts.

LEVEL OF EVIDENCE

III.

Formal Radiologist Interpretations of Intraoperative Spine Radiographs Have Low Clinical Value

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate the clinical relevance, usefulness, and financial implications of intraoperative radiograph interpretation by radiologists in spine surgery.

SUMMARY OF BACKGROUND DATA

Due to rising health care costs, spine surgery is under scrutiny to maximize value-based care. Formal radiographic analysis remains a potential source of unnecessary health care costs, especially for intraoperative radiographs.

MATERIALS AND METHODS

A retrospective cohort analysis was performed on all adult elective spine surgeries at a single institution between July 2020 and July 2021. Demographic and radiographic data were collected, including intraoperative localization and post-instrumentation radiographs. Financial data were obtained through the institution's price estimator. Radiographic characteristics included time from radiographic imaging to completion of radiologist interpretation report, completion of radiologist interpretation report before the conclusion of surgical procedure, clinical relevance, and clinical usefulness. Reports were considered clinically relevant if the spinal level of the procedure was described and clinically useful if completed before the conclusion of the procedure and deemed clinically relevant.

RESULTS

Four hundred eighty-one intraoperative localization and post-instrumentation radiographs from 360 patients revealed a median delay of 128 minutes between imaging and completion of the interpretive report. Only 38.9% of reports were completed before the conclusion of surgery. There were 79.4% deemed clinically relevant and only 33.5% were clinically useful. Localization reports were completed more frequently before the conclusion of surgery (67.2% vs. 34.4%) but with lower clinical relevance (90.1% vs. 98.5%) and clinical usefulness (60.3% vs. 33.6%) than post-instrumentation reports. Each patient was charged $32 to $34 for the interpretation fee, cumulating a minimum total cost of $15,392.

CONCLUSIONS

Formal radiographic interpretation of intraoperative spine radiographs was of low clinical utility for spine surgeons. Institutions should consider optimizing radiology workflows to improve timeliness and clinical relevance or evaluate the necessity of reflexive consultation to radiology for intraoperative imaging interpretation to ensure that value-based care is maximized during spine surgeries.

LEVEL OF EVIDENCE

3.

Does Surgical Day of Week Affect Patient Outcomes and Hospital Costs Following Lumbar Fusion?

Background As the population ages, surgical intervention for degenerative spine conditions is increasing, and this causes a commiserate increase in healthcare expenditures associated with these procedures. Little research has been done on the effect of early-week versus later-week surgeries on patient outcomes, cost, and length of stay (LOS) in patients undergoing lumbar fusion surgery. The purpose of this study is to compare LOS, patient outcomes, and hospital costs between patients having surgery early in the week and later in the week. Methods A retrospective review of 771 patients undergoing a one-, two-, or three-level lumbar fusion from December 2020 to December 2023 at a single institution was performed. Demographics, surgical details, postoperative outcomes and cost were compared between patients who had surgery on Monday, Tuesday, and Wednesday, to those having surgery Thursday or Friday. Univariate and multivariate analyses were performed to compare the groups. Results There were no differences in age, sex, BMI, race, American Society of Anesthesiology (ASA) scores, Charlson Comorbidity Index (CCI) scores, number of operative levels or inpatient/outpatient status between early- and late-week surgeries. Postoperatively the only significant difference was cost, late-week surgeries were, on average, $3,697 more expensive than early-week surgeries ($26,506 vs. $22,809; p<0.001). On multivariate analysis late-week surgeries were 2.47 times more likely to have a non-home discharge (OR: 2.47, 95% CI: 1.24 to 4.95; p=0.010) and 2.19 times more likely to have a 30-day readmission (OR: 2.19, 95% CI:1.01 to 4.74; p=0.044) Additionally, late-week surgeries were $2,041.55 (β:2,041.55, 95% CI: 804.72 to 3,278.38; p=0.001) more expensive than early-week surgeries. Conclusions At our institution, patients undergoing one- to three-level lumbar fusion surgery on Thursday or Friday had a higher risk of non-home discharge, 30-day readmission, and incurred higher cost than those having early-week surgery. Further research is needed to elucidate the reasons for these findings and to evaluate interventions aimed at improving outcomes for patients undergoing surgery later in the week.

Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Methods

The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded.

Results

Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)).

Conclusion

Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis.

Depression State Correlates with Functional Recovery Following Elective Lumbar Spine Fusion

OBJECTIVE

To determine how depression state impacts postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores and achievement of minimum clinically important difference (MCID) following lumbar fusion. Depression has been shown to negatively impact outcomes following numerous orthopedic surgeries. Situational and major clinical depression can differentially affect postoperative outcomes.

METHODS

Adult patients undergoing elective 1-3 level lumbar fusion were reviewed. Patients with a formal diagnosis of major depression were classified as "clinically depressed" whereas patients with at least "mild" PROMIS Depression scores in the absence of formal depression diagnosis were deemed "situationally depressed." analysis of variance testing was used to assess differences within and between groups. Multivariate regression was used to identify features associated with the achievement of MCID.

RESULTS

Two hundred patients were included. The average age was 65.9 ± 12.2 years. 75 patients (37.5%) were nondepressed, 66 patients (33.0%) were clinically depressed, and 59 patients (29.5%) were situationally depressed. Situationally depressed patients had worse preoperative physical function (PF) and pain interference (PI) scores and were more likely to have severe symptoms (P = 0.001, P = 0.001). All groups improved significantly from preoperative baseline scores. All groups met MCID PF at different rates, with highest proportion of situationally depressed reaching this metric (P = 0.03). Rates of achieving MCID PI were not significantly different between groups (P = 0.47). Situational depression was predictive of achieving MCID PF (P = 0.002) but not MCID PI.

CONCLUSIONS

Our study investigated the relationship between depression and postoperative PROMIS scores and identified situationally depressed patients as having the worst preoperative impairment. Despite this, the situationally depressed cohort had the highest likelihood of achieving MCID PF, suggestive of a bidirectional relationship between lumbar degenerative disease and subclinical, situational depression. These findings may help guide preoperative counseling on expectations, and patient selection.

Can local application of vancomycin reduce surgical site infection rate after open lumbar fusion surgery?: A multicenter retrospective cohort study

Surgical site infection (SSI) after posterior open lumbar fusion (POLF) is a major concern for both surgeons and patients. We sought to explore whether local application of vancomycin could decrease the rate of SSI. We reviewed the clinical data of patients who underwent POLF between June 2015 and June 2022 at 3 spinal centers. Patients were divided into those who received local vancomycin (vancomycin group) and those who did not (non-vancomycin group). The SSI rates at 12 months postoperatively were compared between the 2 groups. Although a trend toward a lower infection rate was observed in the vancomycin group than in the non-vancomycin group; the difference was not statistically significant (3.6% vs 5.5%, P = .121). However, we found that the postoperative SSI rate was significantly lower in the vancomycin group than in the non-vancomycin group (4.9% vs 11.4%, P = .041) in patients ≥ 2 fused segments, while there was no significant difference in postoperative SSI rate in patients with single fusion segment (3.1% vs 3.6%, P = .706). The logistic regression analysis indicated that the SSI rate in the non-vancomycin group was approximately 2.498 times higher than that in the vancomycin group (P = .048, odds ratio: 2.498, 95% confidence interval: 1.011-6.617) in patients with ≥2 fused segments. In SSI patients with confirmed pathogens, the SSI rate of Gram-negative bacteria in the vancomycin group was significantly higher than that in the non-vancomycin group (10/14 [71.4%] vs 5/22 [31.8%]), whereas the SSI rate of Gram-positive bacteria in the vancomycin group was significantly lower than that in the non-vancomycin group (4/14 [28.6%] vs 15/22 [68.2%]). Local administration of vancomycin is recommended in patients with ≥2 fused segments as it may facilitate to reduce the postoperative rate of SSI after POLF. Additionally, the local use of vancomycin can decrease the Gram-positive bacterial infections but is not effective against Gram-negative infections, which indirectly leads to an increase in the proportion of Gram-negative infections in SSI patients with confirmed pathogens.

Lumbar Disc Herniation—the Significance of Symptom Duration for the Indication for Surgery

BACKGROUND

Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines.

RESULTS

Symptoms resolve in 60% to 80% of patients with herniated discs in 6-12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6-12 weeks of conservative treatment are recommended in the absence of significant neu - rologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis).

CONCLUSION

Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score.

Association between skin ultrasound parameters and revision surgery after posterior spinal fusion

PURPOSE

The literature is scarce in exploring the role of imaging parameters like ultrasound (US) as a biomarker for surgical outcomes. The purpose of this study is to investigate the associations between skin US parameters and revision surgery following spine lumbar fusion.

METHODS

Posterior lumbar fusion patients with 2-years follow-up were assessed. Previous fusion or revision not due to adjacent segment disease (ASD) were excluded. Revisions were classified as cases and non-revision were classified as controls. US measurements conducted at two standardized locations on the lumbar back. Skin echogenicity of the average dermal (AD), upper 1/3 of the dermal (UD), lower 1/3 of the dermal (LD), and subcutaneous layer were measured. Echogenicity was calculated with the embedded echogenicity function of our institution's imaging platform (PACS). Statistical significance was set at p < 0.05.

RESULTS

A total of 128 patients (51% female, age 62 [54-72] years) were included in the final analysis. 17 patients required revision surgery. AD, UD, and LD echogenicity showed significantly higher results among revision cases 124.5 [IQR = 115.75,131.63], 128.5 [IQR = 125,131.63] and 125.5 [IQR = 107.91,136.50] compared to the control group 114.3 [IQR = 98.83,124.8], 118.5 [IQR = 109.28,127.50], 114 [IQR = 94.20,126.75] respectively.

CONCLUSION

The findings of this study demonstrate a significant association between higher echogenicity values in different layers of the dermis and requiring revision surgery. The results provide insights into the potential use of skin US parameters as predictors for revision surgery. These findings may reflect underlying alterations in collagen. Further research is warranted to elucidate the mechanisms driving these associations.

Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients

PURPOSE

The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS).

METHODS

This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA.

RESULTS

After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA.

CONCLUSIONS

Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.

The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion

INTRODUCTION

Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision.

METHODS

We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22.

RESULTS

We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47).

CONCLUSIONS

The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.