Increased Volume of Surgery for Lumbar Spinal Stenosis and Changes in Surgical Methods and Outcomes: A Nationwide Cohort Study with a 5-Year Follow-Up

Cost-effectiveness analysis of extended endoscopic lumbar foraminotomy (EELF) and transforaminal lumbar interbody fusion (TLIF): a prospective observational study

Lumbar foraminal stenosis can be surgically treated by foraminal decompression or facet joint resection and fusion (transforaminal lumbar interbody fusion, TLIF). While conventional foraminal decompression poses a risk of segmental instability, the endoscopic approach (extended endoscopic lumbar foraminotomy, EELF) resects only the ventral part of the facet joint with a horizontal surgical trajectory. A prospective observational study was performed to analyze the cost-effectiveness of EELF versus TLIF. Patients with dominant unilateral radicular pain from lumbar foraminal stenosis at or above L4-5, without severe central stenosis or instability, were included from January 2021 to February 2023. EELF involved sufficient foraminal widening using a reamer, followed by an endoscopic procedure. The primary outcome was the cost per quality-adjusted life year (QALY) gain at postoperative 12 months. Among 26 patients in each group, the primary analysis included 23 EELF patients (mean age: 72 ± 8 years) and 22 TLIF patients (mean age: 70 ± 8 years). EELF was significantly more cost-effective (EELF: $15,536.0 ± 4,190.0/QALY vs. TLIF: $32,869.4 ± 5,429.3/QALY, p < .001) and demonstrated shorter operating times, less blood loss, and shorter length of stay (p < .05), with no significant difference in clinical outcomes. Thus, EELF could be a cost-effective and less invasive alternative for treating lumbar foraminal stenosis.

Postoperative urinary retention after oblique lumbar interbody fusion under the systematic management protocol

Oblique lumbar interbody fusion (OLIF) is a minimally invasive lateral lumbar fusion technique and patients are discharged 1-2 days after surgery. Because OLIF utilizes a retroperitoneal approach close to the superior hypogastric plexus, postoperative urinary retention (POUR) may not be an uncommon problem. The purpose of this study was to present the incidence and outcomes of POUR with a systematic care protocol. The records of 102 consecutive patients (M:F = 34:68; mean age, 68.0 ± 8.4 years) were retrospectively reviewed. After OLIF, the indwelling urinary catheter was immediately removed, and every patient was encouraged to void within 6 h. The POUR care protocol, following a clinical pathway, was based on residual urine (RU), which was monitored with an ultrasound bladder scan after each voiding or every 6 h for 48 h. The incidence rate of POUR was 44% (45/102) at 24 h, 17% (17/102) at 48 h, and 2% (2/102) at 1 month. Preoperative urological symptoms (odds ratio [OR] 3.2) and violation of the protocol (OR 28.3) were risk factors at 24 h. At 48 h, violation of the protocol was the only risk factor (OR 9.6). Identifying risk factors and a preemptive care protocol may reduce permanent POUR.

Disparities in Sporadic Vestibular Schwannoma Initial Presentation Between a Public Safety Net Hospital and Tertiary Academic Medical Center at the Same Zip Code 2010 to 2020

INTRODUCTION

Treatment of vestibular schwannoma (VS) has been extensively studied, but a gap in knowledge exists demonstrating how racial and socioeconomic status influence VS presentation. Our institution has a unique setting with a public safety net hospital (PSNH) and tertiary academic medical center (TAMC) in the same zip code, which we study to evaluate initial VS presentation disparities in patient populations presenting to these hospital settings.

METHODS

Retrospective chart review was performed of all adult patients (n = 531) presenting 2010 to 2020 for initial VS evaluation at TAMC (n = 462) and PSNH (n = 69). Ethnicity, insurance, maximum tumor size, audiometry, initial treatment recommendation, treatment received, and follow up were recorded and statistical analysis performed to determine differences.

RESULTS

Average age at diagnosis (51.7 ± 13.6 TAMC vs 52.3 ± 12.4 PSNH) and gender (58.4% TAMC vs 52.2% PSNH female) were similar. Patients' insurance (TAMC 75.9% privately insured vs PSNH 82% Medicaid) and racial/ethnic profiles (TAMC 67.7% White and 10.0% Hispanic/Latinx, vs PSNH 4.8% White but 59.7% Hispanic/Latinx) were significantly different. Tumor size was larger at PSNH (20.2 ± 13.3 mm) than TAMC (16.6 ± 10.0 mm). Hearing was more impaired at PSNH than TAMC (mean pure tone average 58.3 dB vs 43.9 dB, word recognition scores 52.3% vs 68.2%, respectively). Initial treatment recommendations and treatment received may include more than 1 modality. TAMC patients were offered 66.7% surgery, 31.2% observation, and 5.2% radiation, while PSNH patients offered 50.7% observation, 49.3% surgery, and 8.7% radiation. TAMC patients received 62.9% surgery, 32.5% observation, and 5.3% radiation, while PSNH patients received 36.2% surgery, 59.4% observation, and 14.5% radiation. Follow up and treatment at the same facility was not significantly different between hospitals.

CONCLUSIONS

Hearing was worse and tumor size larger in patients presenting to PSNH. Despite worse hearing status and larger tumor size, the majority of PSNH patients were initially offered observation, compared to TAMC where most patients were initially offered surgery.

Perioperative Blindness in Spine Surgery: A Scoping Literature Review

Perioperative vision loss (POVL) is a devastating surgical complication that impacts both the recovery from surgery and quality of life, most commonly occurring after spine surgery. With rates of spine surgery dramatically increasing, the prevalence of POVL will increase proportionately. This scoping review aims to aggregate the literature pertinent to POVL in spine surgery and consolidate recommendations and preventative measures to reduce the risk of POVL. There are several causes of POVL, and the main contribution following spine surgery is ischemic optic neuropathy (ION). Vision loss often manifests immediately following surgery and is irreversible and severe. Diffusion weighted imaging has recently surfaced as a diagnostic tool to identify ION. There are no effective treatments; therefore, risk stratification for counseling and prevention are vital. Patients undergoing prone surgery of long duration and/or with significant expected blood loss are at greatest risk. Future research is necessary to develop effective treatments.

Screening patients requiring secondary lumbar surgery for degenerative lumbar spine diseases: a nationwide sample cohort study

This study aims to identify healthcare costs indicators predicting secondary surgery for degenerative lumbar spine disease (DLSD), which significantly impacts healthcare budgets. Analyzing data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of Republic of Korea (ROK), the study included 3881 patients who had surgery for lumbar disc herniation (LDH), lumbar spinal stenosis without spondylolisthesis (LSS without SPL), lumbar spinal stenosis with spondylolisthesis (LSS with SPL), and spondylolysis (SP) from 2006 to 2008. Patients were categorized into two groups: those undergoing secondary surgery (S-group) and those not (NS-group). Surgical and interim costs were compared, with S-group having higher secondary surgery costs ($1829.59 vs $1618.40 in NS-group, P = 0.002) and higher interim costs ($30.03; 1.86% of initial surgery costs vs $16.09; 0.99% of initial surgery costs in NS-group, P < 0.0001). The same trend was observed in LDH, LSS without SPL, and LSS with SPL (P < 0.0001). Monitoring interim costs trends post-initial surgery can effectively identify patients requiring secondary surgery.

The Norwegian degenerative spondylolisthesis and spinal stenosis (NORDSTEN) study: study overview, organization structure and study population

PURPOSE

To provide an overview of the The Norwegian Degenerative spondylolisthesis and spinal stenosis (NORDSTEN)-study and the organizational structure, and to evaluate the study population.

METHODS

The NORDSTEN is a multicentre study with 10 year follow-up, conducted at 18 public hospitals. NORDSTEN includes three studies: (1) The randomized spinal stenosis trial comparing the impact of three different decompression techniques; (2) the randomized degenerative spondylolisthesis trial investigating whether decompression surgery alone is as good as decompression with instrumented fusion; (3) the observational cohort tracking the natural course of LSS in patients without planned surgical treatment. A range of clinical and radiological data are collected at defined time points. To administer, guide, monitor and assist the surgical units and the researchers involved, the NORDSTEN national project organization was established. Corresponding clinical data from the Norwegian Registry for Spine Surgery (NORspine) were used to assess if the randomized NORDSTEN-population at baseline was representative for LSS patients treated in routine surgical practice.

RESULTS

A total of 988 LSS patients with or without spondylolistheses were included from 2014 to 2018. The clinical trials did not find any difference in the efficacy of the surgical methods evaluated. The NORDSTEN patients were similar to those being consecutively operated at the same hospitals and reported to the NORspine during the same time period.

CONCLUSION

The NORDSTEN study provides opportunity to investigate clinical course of LSS with or without surgical interventions. The NORDSTEN-study population were similar to LSS patients treated in routine surgical practice, supporting the external validity of previously published results.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018.

Trends of Surgical Service Utilization for Lumbar Spinal Stenosis in South Korea: A 10-Year (2010-2019) Cross-Sectional Analysis of the Health Insurance Review and Assessment Service-National Patient Sample Data

Background and Objectives: This retrospective, cross-sectional, and descriptive study used claims data from the Korean Health Insurance Review and Assessment Service (HIRA) between 2010 and 2019 to analyze the trend of surgical service utilization in patients with lumbar spinal stenosis (LSS). Materials and Methods: The national patient sample data provided by the HIRA, which consisted of a 2% sample of the entire Korean population, was used to assess all patients who underwent decompression or fusion surgery at least once in Korea, with LSS as the main diagnosis from January 2010 to December 2019. An in-depth analysis was conducted to examine the utilization of surgical services, taking into account various demographic characteristics of patients, the frequency of claims for different types of surgeries, reoperation rates, the specific types of inpatient care associated with each surgery type, prescribed medications, and the overall expense of healthcare services. Results: A total of 6194 claims and 6074 patients were analyzed. The number of HIRA claims for patients increased from 393 (2010) to 417 (2019) for decompression, and from 230 (2010) to 244 (2019) for fusion. As for the medical expenses of surgery, there was an increase from United States dollar (USD) 867,549.31 (2010) to USD 1,153,078.94 (2019) for decompression and from USD 1,330,440.37 (2010) to USD 1,780,026.48 (2019) for fusion. Decompression accounted for the highest proportion (65.8%) of the first surgeries, but more patients underwent fusion (50.6%) than decompression (49.4%) in the second surgery. Across all sex and age groups, patients who underwent fusion procedures experienced longer hospital stays and incurred higher medical expenses for their inpatient care. Conclusion: The surgical service utilization of patients with LSS and the prescribing rate of opioids and non-opioid analgesics for surgical patients increased in 2019 compared to 2010. From mid-2010 onward, claims for fusion showed a gradual decrease, whereas those for decompression showed a continuously increasing trend. The findings of this study are expected to provide basic research data for clinicians, researchers, and policymakers.

Incidence and treatment trends of infectious spondylodiscitis in South Korea: A nationwide population-based study

The incidence of infectious spondylodiscitis (IS) has increased in recent years due to an increase in the numbers of older patients with chronic diseases, as well as patients with immunocompromise, steroid use, drug abuse, invasive spinal procedures, and spinal surgeries. However, research focusing on IS in the general population is lacking. This study investigated the incidence and treatment trends of IS in South Korea using data obtained from the Health Insurance Review and Assessment Service. A total of 169,244 patients (mean age: 58.0 years) diagnosed from 2010 to 2019 were included in the study. A total of 10,991 cases were reported in 2010 and 18,533 cases in 2019. Hence, there was a 1.5-fold increase in incidence rate per 100,000 people from 22.90 in 2010 to 35.79 in 2019 (P < 0.05). The incidence rate of pyogenic spondylodiscitis per 100,000 people increased from 15.35 in 2010 to 33.75 in 2019, and that of tuberculous spondylodiscitis decreased from 7.55 in 2010 to 2.04 in 2019 (P < 0.05, respectively). Elderly individuals ≥ 60 years of age accounted for 47.6% (80,578 patients) of all cases of IS. The proportion of patients who received conservative treatment increased from 82.4% in 2010 to 85.8% in 2019, while that of patients receiving surgical treatment decreased from 17.6% to 14.2% (P < 0.05, respectively). Among surgical treatments, the proportions of corpectomy and anterior fusion declined, while proportion of incision and drainage increased (P < 0.05, respectively). The total healthcare costs increased 2.9-fold from $29,821,391.65 in 2010 to $86,815,775.81 in 2019 with a significant increase in the ratio to gross domestic product. Hence, this population-based cohort study demonstrated that the incidence rate of IS has increased in South Korea. The conservative treatment has increased, while the surgical treatment has decreased. The socioeconomic burden of IS has increased rapidly.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

A cost-utility analysis between decompression only and fusion surgery for elderly patients with lumbar spinal stenosis and sagittal imbalance

Lumbar spinal stenosis (LSS) and sagittal imbalance are relatively common in elderly patients. Although the goals of surgery include both functional and radiological improvements, the criteria of correction may be too strict for elderly patients. If the main symptom of patients is not forward-stooping but neurogenic claudication or pain, lumbar decompression without adding fusion procedure may be a surgical option. We performed cost-utility analysis between lumbar decompression and lumbar fusion surgery for those patients. Elderly patients (age > 60 years) who underwent 1-2 levels lumbar fusion surgery (F-group, n = 31) or decompression surgery (D-group, n = 40) for LSS with sagittal imbalance (C7 sagittal vertical axis, C7-SVA > 40 mm) with follow-up ≥ 2 years were included. Clinical outcomes (Euro-Quality of Life-5 Dimensions, EQ-5D; Oswestry Disability Index, ODI; numerical rating score of pain on the back and leg, NRS-B and NRS-L) and radiological parameters (C7-SVA; lumbar lordosis, LL; the difference between pelvic incidence and lumbar lordosis, PI-LL; pelvic tilt, PT) were assessed. The quality-adjusted life year (QALY) and incremental cost-effective ratio (ICER) were calculated from a utility score of EQ-5D. Postoperatively, both groups attained clinical and radiological improvement in all parameters, but NRS-L was more improved in the F-group (p = 0.048). ICER of F-group over D-group was 49,833 US dollars/QALY. Cost-effective lumbar decompression may be a recommendable surgical option for certain elderly patients, despite less improvement of leg pain than with fusion surgery.

Effectiveness and safety of decompression alone versus decompression plus fusion for lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis

Background

There have been lingering controversies reported decompression and plus fusion. And the relative safety of fusion in addition to standard decompression remains unclear. This study aimed to assess the effectiveness and safety of decompression alone or combined with fusion in lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS).

Methods

In this systematic review and meta-analysis, we searched the databases of PubMed, Embase, Cochrane Library, and Web of Science for relevant literature from their inception to 28th December 2021. We identified the eligible studies based on the PICOS principles, populations (LSS with DS), interventions (decompression alone), controls (decompression combined with fusion), outcomes [overall reoperation rate, complications, Oswestry Disability Index (ODI), operative time, the amount of blood lost, length of stay (LOS), and visual analog scales (VAS)], study design (cohort studies). Quality assessment for individual study was performed with the Newcastle-Ottawa Scale (NOS).

Results

In all, 12 articles involving a total of 14,693 patients were finally included in the study, the majority of patients underwent decompression alone (DA group: n=11,598) and the rest underwent decompression associated with fusion (FU group: n=3,095). The quality of most of the included studies was regarded as high quality. The results indicated that the FU group had a higher rate of complication [relative risk (RR): 1.770, 95% confidence interval (CI): 1.485 to 2.110], longer operative time [weighted mean difference (WMD): 51.037, 95% CI: 13.743 to 88.330], and increased blood loss (WMD: 258.354, 95% CI: 150.468 to 366.239) than the DA group (all P<0.05), with no significant differences for overall reoperation rate (RR: 0.879, 95% CI: 0.432 to 1.786), ODI (WMD: −2.569, 95% CI: −6.548 to 1.409), LOS (WMD: 3.838, 95% CI: −2.172 to 9.848), and VAS found between the two groups (P>0.05).

Conclusions

In patients with LSS + DS, the effectiveness and safety of decompression alone may be superior to decompression plus fusion in terms of complication rate, operative time, and the amount of bleeding. However, more high-quality literature is needed in the future to confirm the best treatment choice for patients with LSS + DS.

Risk factors for reoperation after lumbar spine surgery in a 10-year Korean national health insurance service health examinee cohort

Degenerative lumbar spine disease is becoming increasingly prevalent in the aging population. Surgical treatment is the standard treatment modality for intractable cases, but the reoperation rate remains high. We conducted this study to longitudinally evaluate the impact of health risk factors on the risk of lumbar spine reoperation in Koreans aged over 40 years. Subjects aged > 40 years who underwent their first lumbar spinal surgery between January 2005 and December 2008 were selected and followed up until 2015. A total of 6300 people were included. The reoperation rate during the 10-year follow-up period was 13.2% (831/6300 patients). The reoperation rate was the highest in patients in their 60 s (15.4%, P < 0.05). The reoperation rates were also significantly higher in men (vs. women: 14.7% vs. 11.7%, P < 0.05), smokers (vs. non-smokers: 15.2% vs. 12.7%, P < 0.05), alcohol drinkers (vs. non-drinkers: 14.7% vs. 12.4%, P < 0.05), and those with a higher Charlson Comorbidity Index (CCI) score (CCI 0, 11.6%; 1–2, 13.2%; and ≥ 3, 15%; P < 0.05). Among patients undergoing lumbar spine surgery, reoperation is performed in 13.2% of patients within 10 years. Male sex, age in the 60 s, alcohol use, smoking, higher Hgb and a high CCI score increased the risk of reoperation after lumbar spine operation.

Is Discretionary Care Associated with Safety Among Medicare Beneficiaries Undergoing Spine Surgery?

BACKGROUND

Spine surgery and its corresponding costs have increased in recent years and are variable across geographic regions. Discretionary care is the component of spending variation that is independent of illness severity, age, and regional pricing. It is unknown whether greater discretionary care is associated with improved safety for patients undergoing spine surgery, as we would expect from value-based health care.

METHODS

We conducted an analysis of 5 spine surgery cohorts based on Medicare claims from 2013 to 2017. Patients were grouped into quintiles based on the Dartmouth Atlas End-of-Life Inpatient Care Index (EOL), reflecting regional spending variation attributed to discretionary care. Multivariable regression examined the association between discretionary care and safety measures while controlling for age, sex, race, comorbidity, and hospital features.

RESULTS

We observed a threefold to fourfold variation in 90-day episode-of-care cost across regions, depending on the cohort. Spine-specific spending was correlated with EOL quintile, confirming that spending variation is due more to discretionary care than it is to pricing, age, or illness severity. Greater spending across EOL quintiles was not associated with improved safety, and, in fact, was associated with poorer safety in some cohorts. For example, all-cause readmission was greater in the high-spending EOL quintile relative to the low-spending EOL quintile among the "fusion, except cervical" cohort (14.2% vs. 13.1%; OR = 1.10; 95% CI = 1.05 to 1.20), the "complex fusion" cohort (28.0% vs. 25.4%; OR = 1.15; 95% CI = 1.01 to 1.30), and the "cervical fusion" cohort (15.0% vs. 13.6%; OR = 1.12; 95% CI = 1.05 to 1.20).

CONCLUSIONS

Wide variation in spending was not explained by differences in illness severity, age, or pricing, and increased discretionary care did not enhance safety. These findings point to inefficient use of health-care resources, a potential focus of reform.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up

Objective

The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease.

Methods

The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years.

Results

The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years.

Conclusion

Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Epidemiology of senile spinal diseases: a study based on the Health Insurance Review & Assessment Service database

According to the Statistics Korea in 2020, the elderly population aged 65 or older accounted for 15.7% of the total population, and by 2025 it will reach 20.3%, which will enter the super-aged society. In an aging society, many degenerative diseases occur with age. In particular, the spine is a structure that acts as a pillar of our body, and as we age, degenerative changes come. Representative senile spinal diseases include disc disease, spinal stenosis, spinal spondylolisthesis, scoliosis, kyphosis, and flat back syndrome. This study intends to examine the epidemiologic characteristics and trends of senile spinal diseases using Korean Health Insurance Review & Assessment Service database from 2010 to 2019. All of the senile spinal diseases have gradually increased in the number of patients and cost over the last 10 years. In addition, the proportion of those aged 60 and over increased among those diagnosed. And fusion surgery and discectomy also increased in the last 10 years, and the treatment cost and ratio of over 60 years old increased. Korea has already become an aging society. So, in the future, senile diseases will increase further, and among them, senile spinal diseases will steadily increase. As a result, the frequency and cost of surgery will continue to increase. Efforts are needed to understand this trend and to prevent senile spinal diseases. For example, regular exercise, proper posture and habits, adequate nutrition, and efforts such as quitting smoking should be required. When these efforts are made, more healthy old life will be achieved.

A prospective study of non-surgical versus surgical treatment for lumbar spinal stenosis without instability

OBJECTIVE

Even if analyzed through meta-analyses or systemic reviews ensued lately, we could say that at least it is inconclusive which of the surgical or non-surgical treatment to lumbar spinal stenosis is better particularly in short to intermediate-term. This study compared non-surgical and surgical outcomes in surgical candidates for lumbar spinal stenosis (LSS).

METHODS

Surgical candidates for LSS were prospectively screened. Patients were offered the option to be enrolled in a randomized cohort, an observational cohort, or not to participate. Patient-reported outcomes were evaluated at baseline, and at 1, 3, 6, and 12 months. The primary outcomes were measures of pain and functional outcomes such as the Korean version of the Oswestry Disability Index (K-ODI), the EuroQol 5-Dimension instrument (EQ-5D), and 36-Item Short-Form Health Survey (SF-36).

RESULTS

One hundred and ten patients were enrolled in the randomized cohort and 37 patients in the observational cohort. Among them, 97 patients received non-surgical treatment, and 50 patients underwent surgical treatment. At 12 months, the non-surgical treatment group had less improvements in the primary outcome measures of back pain (mean change: non-surgery, 2.34 vs. surgery, 3.99), leg pain (2.92 vs. 3.40), K-ODI (5.12 vs. 8.31), EQ-5D utility index (0.19 vs. 0.25), and EQ-5D VAS (9.68 vs. 16.0). Most SF-36 section parameters also showed less improvement in the non-surgical treatment group than in the surgical treatment group throughout the 12-month follow-up.

CONCLUSIONS

In LSS patients without instability, non-surgical treatment resulted in less pain improvement and functional recovery through 1 year.

The Long-term Reoperation Rate Following Surgery for Lumbar Stenosis: A Nationwide Sample Cohort Study With a 10-year Follow-up

STUDY DESIGN

Retrospective cohort study of a nationwide sample database.

OBJECTIVE

The objective of the present study was to compare the long-term incidence of reoperation for lumbar spinal stenosis (LSS) after anterior fusion, posterior fusion, and decompression.

SUMMARY OF BACKGROUND DATA

Surgical treatment for LSS can be largely divided into 2 categories: decompression only and decompression with fusion. A previous nationwide study reported that fusion surgery was performed in 10% of patients with LSS, and the 10-year reoperation rate was approximately 17%. However, with the development of surgical techniques and changes in surgical trends, these results should be reassessed.

METHODS

The National Health Insurance Service-National Sample Cohort of the Republic of Korea was utilized to establish a cohort of adult patients (N = 1400) who first underwent surgery for LSS during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using a Fine and Gray regression model after adjustment for sex, age, diabetes, osteoporosis, Charlson comorbidity index, severity of disability, type of medical coverage, and type of hospital.

RESULTS

The overall cumulative incidence of reoperation was 6.2% at 2 years, 10.8% at 5 years, and 18.4% at 10 years. The cumulative incidence of reoperation was 20.6%, 12.6%, and 18.6% after anterior fusion, posterior fusion, and decompression, respectively, at 10 years postoperatively (P = 0.44). The first surgical technique did not affect the reoperation type (P = 0.27). Decompression was selected as the surgical technique for reoperation in 83.5% of patients after decompression, in 72.7% of patients after anterior fusion, and in 64.3% of patients after posterior fusion.

CONCLUSION

The initial surgical technique did not affect reoperation during the 10-year follow-up period. Decompression was the most commonly used technique for reoperation.

LEVEL OF EVIDENCE

4.

Does increasing age impact clinical and radiographic outcomes following lumbar spinal fusion?

BACKGROUND CONTEXT

Despite the growing senior population within the United States, there is a lack of consensus regarding the safety and efficacy of performing lumbar spinal fusion for this population.

PURPOSE

To evaluate the clinical and radiographic outcomes in different age cohorts following lumbar spinal fusion.

STUDY DESIGN

Retrospective cohort analysis.

PATIENT SAMPLE

Analysis of 1,184 patients who underwent posterolateral lumbar fusion from 2011 to 2018. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, had a lumbar fracture, tumor, or infection, or had fusions involving the thoracic spine, high-grade spondylolisthesis, or concomitant deformity. Of the 1,184 patients, 850 patients were included. Patients were divided into three roughly equal groups for analysis: young (18-54 years), middle-aged (55-69 years), and senior (≥70 years).

OUTCOME MEASURES

Visual Analog Scale Back/Leg pain, and Oswestry Disability Index (ODI) were collected, and achievement of minimal clinically important difference was evaluated. Lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and PI-LL difference were measured on radiographs. Rates of postoperative complications were analyzed.

METHODS

Several radiographic parameters were measured using plain radiographs obtained at preoperative, immediately postoperative (standing radiographs performed on postoperative day 1), and most recent follow-up visits. Preoperative and final patient-reported outcomes, along with demographic information, were obtained all patients. Binary outcome variables were compared between groups with multivariate logistic regression, and continuous outcome variables were compared using multivariate linear regression, with age 18 to 54 years used as the reference. Multivariate regressions were used to compare outcomes between cohorts while controlling baseline characteristics.

RESULTS

A total of 850 patients were included; 330 young (38.80%), 317 middle-aged (37.30%), and 203 senior (23.90%). Seniors had higher postoperative length of stay compared to younger patients (p<.001). Younger patients had worse final ODI scores compared to middle-aged patients (p=.002). Seniors had higher rates of proximal ASD (p=.002) compared to young patients. There was no difference in achievement of minimal clinically important differences (MCID) between all three groups.

CONCLUSIONS

Senior patients have significant improvement in patient-reported clinical outcomes, despite having greater comorbidities, and longer length of stay. However, given a general lack of achievement of MCID across all cohorts, these findings suggest the need for a critical re-evaluation of the role of lumbar spinal fusion in the management of patients with refractory radiculopathic and/or neurogenic claudication symptoms.

Natural Course and Diagnosis of Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Lumbar spinal stenosis (LSS) is defined as a degenerative disorder showing a narrowing of the spinal canal. The diagnosis is straightforward in cases with typical neurogenic claudication symptoms and unequivocal imaging findings. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis and clinical complaint. The radiologic diagnosis of LSS is widely discussed in the literature. The best diagnostic test for the diagnosis of LSS is magnetic resonance imaging (MRI). However, canal diameter measurements have not gained much consensus from radiologists, whereas qualitative measures, such as cerebrospinal fluid space obliteration, have achieved greater consensus. Instability can best be defined by standing lateral radiograms and flexion-extension radiograms. For cases showing typical neurogenic claudication symptoms and unequivocal imaging findings, the diagnosis is straightforward. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis (computed tomography and MRI) and clinical complaint. In fact, recent MRI studies have shown that mild-to-moderate stenosis can also be found in asymptomatic individuals. Routine electrophysiological tests such as lower extremity electromyography, nerve conduction studies, F-wave, and H-reflex are not helpful in the diagnosis and outcome prediction of LSS. The electrophysiological recordings are complementary to the neurologic examination and can provide confirmatory information in less obvious clinical complaints. However, in the absence of reliable evidence, imaging studies should be considered as a first-line diagnostic test in the diagnosis of degenerative LSS.

The problems associated with revision surgery

This article highlights the issue related to revision surgery in spine and the possible implications in the next future. These slides can be retrieved under Electronic Supplementary Material.

Multi-segmental lumbar spinal stenosis treated with Dynesys stabilization versus lumbar fusion in elderly patients: a retrospective study with a minimum of 5 years' follow-up

INTRODUCTION

Middle- and long-term outcomes of multi-segmental lumbar spinal stenosis treated with Dynesys stabilization (DS) have rarely been reported. Older age and multi-segmental degeneration may be positive factors in achieving satisfactory outcomes following DS. The present study aimed to compare the middle- and long-term outcomes of DS with lumbar fusion for treatment of multi-segmental lumbar spinal stenosis (ms-LSS) in elderly patients.

MATERIALS AND METHODS

This study retrospectively analyzed patients with ms-LSS treated by DS or lumbar fusion from January 2011 to April 2013. Twenty-two patients were included in the Dynesys group, and 44 patients treated by lumbar fusion and rigid fixation were included in the fusion group. Clinical outcomes were assessed by VAS and ODI. Radiological outcomes were measured by range of motion (ROM) of stabilized segments and the proximal adjacent segment, intervertebral disc height (DH) and L1-S1 lumbar lordosis angle (LL). Modified Pfirrmann grade score was used to access disc degeneration.

OUTCOMES

The mean follow-up time of the Dynesys group and fusion group was 68.50 ± 6.40 and 70.14 ± 7.26 months, respectively. Baseline data were similar between the two groups. There were no significant differences between the two groups in terms of improvement of clinical outcomes (VAS and ODI). DS preserved a certain degree of ROM (3.74 ± 2.00) of surgical segments. ROM of proximal adjacent segment underwent an increase in both groups at the final follow-up. The DH of the surgical segments and proximal adjacent segment in both groups was significantly lower than that before surgery (P = 0.000). LL of both groups improved (P = 0.000), and there was no significant difference between the two groups. The modified Pfirrmann score of proximal adjacent segment of both groups increased at the final follow-up. The fusion group underwent a more significant increase (P = 0.000), whereas the inter-group difference showed no significance (P = 0.090).

CONCLUSION

DS is a safe and effective surgical treatment of multi-segmental lumbar spinal stenosis in the elderly population. DS preserves a certain degree of mobility of surgical segments.

The Long-term Reoperation Rate Following Surgery for Lumbar Herniated Intervertebral Disc Disease: A Nationwide Sample Cohort Study With a 10-year Follow-up

STUDY DESIGN

A retrospective cohort study of a nationwide sample database.

OBJECTIVE

The objective of the present study was to compare the long-term incidence of reoperation for lumbar herniated intervertebral disc disease (HIVD) after major surgical techniques (open discectomy, OD; laminectomy; percutaneous endoscopic lumbar discectomy, PELD; fusion).

SUMMARY OF BACKGROUND DATA

HIVD is a major spinal affliction; if the disease is intractable, surgery is recommended. Considering both the aging of patients and the chronicity of lumbar degenerative disease, the effect of surgical treatment for the lumbar spine should be durable for as long as possible.

METHODS

The National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Republic of Korea was utilized to establish a cohort of adult patients (N = 1856) who underwent first surgery for lumbar HIVD during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using the Fine and Gray regression model after adjustment for age, gender, Charlson comorbidity score, osteoporosis, diabetes, the severity of disability, insurance type, and hospital type.

RESULTS

The overall cumulative incidences of reoperation were 4% at 1 year, 6% at 2 years, 8% at 3 years, 11% at 5 years, and 16% at 10 years. The cumulative incidences of reoperation were 16%, 14%, 16%, and 10% after OD, laminectomy, PELD, and fusion, respectively, at 10 years postoperation, with no difference among the surgical techniques. However, the distribution of reoperation types was significantly different according to the first surgical technique (P < 0.01). OD was selected as the reoperation surgical technique in 80% of patients after OD and in 81% of patients after PELD.

CONCLUSION

The probability of reoperation did not differ among OD, laminectomy, PELD, and fusion during the 10-year follow-up period. However, OD was the most commonly used technique in reoperation.

LEVEL OF EVIDENCE

4.

The Rates of LSS Surgery in Norwegian Public Hospitals: A Threefold Increase From 1999 to 2013

STUDY DESIGN

Retrospective administrative database study.

OBJECTIVE

To assess temporal and regional trends, and length of hospital stay, in lumbar spinal stenosis (LSS) surgery in Norwegian public hospitals from 1999 to 2013.

SUMMARY OF BACKGROUND DATA

Studies from several countries have reported increasing rates of LSS surgery over the last decades. No such data have been presented from Norway.

METHODS

A database consisting of discharges from all Norwegian public hospitals was established. Inclusion criteria were discharges including a surgical procedure of lumbar spinal decompression and/or fusion in combination with an International Statistical Classification of Diseases and Related Health Problems, 10th Revision diagnosis of Spinal Stenosis (M48.0) or Other Spondylosis with Radiculopathy (M47.2), and a patient age of 18 years or older. Discharges with diagnoses indicating deformity, that is, spondylolisthesis or scoliosis were not included.

RESULTS

During the 15-year period, 19,543 discharges were identified. The annual rate of decompressions increased from 10.7 to 36.2 and fusions increased from 2.5 to 4.4 per 100,000 people of the general Norwegian population. The proportion of fusion surgery decreased from 19.3% to 10.9%. Among individuals older than 65 years, the annual rate of surgery per 10,000, including both decompressions and fusions, more than quadrupled from 40.2 to 170.3. The regional variation was modest, differing with a factor of 1.4 between the region with the highest and the lowest surgical rates. The mean length of hospital stay decreased from 11.0 (standard deviation 8.0) days in 1999 to 5.0 (4.6) days in 2013, but patients who received fusion surgery stayed on average 3.6 days longer than those who received decompression only.

CONCLUSION

The rate of LSS surgery more than tripled in Norway from 1999 to 2013. The mean length of hospital stay was reduced from 11 to 5 days.

LEVEL OF EVIDENCE

N/A.