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Goudihalli SR, Brar HS, Patil M, Tanwar V, Mittal MK, Swamy AC, Pathak A. Spine Surgery in a Geriatric Population. Is it Really Different? Neurol India 2024; 72:345-351. [PMID: 38691480 DOI: 10.4103/ni.ni_1102_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 11/08/2019] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Spinal degenerative disorders are a major cause of morbidity in the elderly resulting in high dependency. Most of them have a trend to be managed conservatively considering age, comorbidities, and apprehensions of surgical complications. Surgical intervention at early stage with appropriate indications can have better outcomes rather than conservative management in fit patients. The objective of the study is to evaluate the functional outcome in geriatric patients > 60 years who have undergone various spinal procedures for degenerative spine. METHODS The study is retrospective, which includes all cases of spinal degenerative disease operated between 2014 and 2016. They were divided into geriatric (>60 years) and non-geriatric cohorts. These include all patients undergoing spinal decompression and/or instrumentation for degenerative disorders of the spine. Patients were interviewed for their functional outcomes in the follow-up period. RESULTS A total of 184 spine cases were operated upon by a single surgeon, out of which a total of 139 cases were operated for the spinal degenerative condition. Forty-eight patients underwent lumbar spinal fusion procedures, 67 underwent non-instrumented lumbar decompression, and 24 patients underwent cervical procedures. These were further divided into 65 geriatric cases and 74 non-geriatric cases. The outcome was assessed with improvement and functional outcomes for spinal disability. Statistical analysis was performed using SPSS 20. CONCLUSION It is concluded that surgical intervention for spinal problems in geriatric patients is not different from the general population. The outcome is also satisfactory provided, the choice of surgical procedure as per its indication is appropriate. The usual preoperative evaluation for the geriatric age group is very important. The performance status before surgery and the comorbidities have a direct bearing on the outcome in these patients.
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Affiliation(s)
| | | | - Mandar Patil
- Department of Neurosurgery, Fortis Hospital, Mohali, Punjab, India
| | - Vineet Tanwar
- Department of Neurosurgery, Fortis Hospital, Mohali, Punjab, India
| | - Mohit K Mittal
- Department of Anaesthesia, Fortis Hospital, Mohali, Punjab, India
| | - Adarsh C Swamy
- Department of Anaesthesia, Fortis Hospital, Mohali, Punjab, India
| | - Ashis Pathak
- Department of Neurosurgery, Fortis Hospital, Mohali, Punjab, India
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2
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Hikata T, Takahashi Y, Ishihara S, Shinozaki Y, Nimoniya K, Konomi T, Fujii T, Funao H, Yagi M, Hosogane N, Ishii K, Nakamura M, Matsumoto M, Watanabe K. Risk factors for early reoperation in patients after posterior lumbar interbody fusion surgery. A propensity-matched cohort analysis. J Orthop Sci 2024; 29:83-87. [PMID: 36564234 DOI: 10.1016/j.jos.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Reoperation is usually associated with poor results and increased morbidity and hospital costs. However, the rates, causes, and risk factors for reoperation in patients undergoing lumbar spinal fusion surgery remain controversial. This study aimed to identify the risk factors for early reoperation after posterior lumbar interbody fusion surgery and to compare the clinical outcomes between patients who underwent reoperation and those who did not. METHODS We investigated a multicenter medical record database of 1263 patients who underwent posterior lumbar interbody fusion surgery between 2012 and 2015. A total of 72 (5.7%) reoperations within two years after surgery were identified and were propensity-matched for age, sex, number of fusion segments, and surgeon's experience. RESULTS We analyzed a total of 114 patients (57 who underwent reoperation (R group) and 57 who did not (C group)). The mean age was 62.6 ± 13.4 years, with 78 men and 36 women. The mean number of fused segments was 1.2 ± 0.5. Surgical site infection was the most common cause of reoperation. There were significant differences in the incidence of diabetes mellitus (p = 0.024), preoperative ambulation status (p = 0.046), and ASA grade (p < 0.001) between the C and R groups. The recovery rate of the Japanese Orthopaedic Association score was significantly lower in the R group compared to the C group (R: 50.5 ± 28.8%, C: 63.9 ± 33.7%, p = 0.024). There were significant differences in the bone fusion rate (R: 63.2%, C: 96.5%, p < 0.001) and incidence of screw loosening (R: 31.6%; C: 10.5%; p = 0.006). CONCLUSION Diabetes mellitus, preoperative ambulation status, and ASA grade were significant risk factors for early reoperation following posterior lumbar interbody fusion surgery. The patients who underwent early reoperation had worse clinical outcomes than those who did not.
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Affiliation(s)
- Tomohiro Hikata
- Department of Orthopaedic Surgery, Kitasato University Kitasato Institute Hospital, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Yohei Takahashi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Shinichi Ishihara
- Department of Orthopaedic Surgery, Ota Memorial Hospital, Tochigi, Japan; KSRG (Keio Spine Research Group), Japan
| | - Yoshio Shinozaki
- Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan; KSRG (Keio Spine Research Group), Japan
| | - Ken Nimoniya
- Department of Orthopedic Surgery, Shizuoka City Shimizu Hospital, Shizuoka, Japan; KSRG (Keio Spine Research Group), Japan
| | - Tsunehiko Konomi
- Department of Orthopedic Surgery, Murayama medical Center, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Takeshi Fujii
- Department of Orthopaedic Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, International University of Health and Welfare, Narita Hospital, Chiba, Japan; KSRG (Keio Spine Research Group), Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Naobumi Hosogane
- Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Ken Ishii
- Department of Orthopaedic Surgery, International University of Health and Welfare, Narita Hospital, Chiba, Japan; KSRG (Keio Spine Research Group), Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; KSRG (Keio Spine Research Group), Japan.
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Melcher C, Hussain I, Kirnaz S, Goldberg JL, Sommer F, Navarro-Ramirez R, Medary B, Härtl R. Use of a High-Fidelity Training Simulator for Minimally Invasive Lumbar Decompression Increases Working Knowledge and Technical Skills Among Orthopedic and Neurosurgical Trainees. Global Spine J 2023; 13:2182-2192. [PMID: 35225716 PMCID: PMC10538343 DOI: 10.1177/21925682221076044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective comparative study. OBJECTIVE To quantify the educational benefit to surgical trainees of using a high-fidelity simulator to perform minimally invasive (MIS) unilateral laminotomy for bilateral decompression (ULBD) for lumbar stenosis. METHODS Twelve orthopedic and neurologic surgery residents performed three MIS ULBD procedures over 2 weeks on a simulator guided by established AO Spine metrics. Video recording of each surgery was rated by three blinded, independent experts using a global rating scale. The learning curve was evaluated with attention to technical skills, skipped steps, occurrence of errors, and timing. A knowledge gap analysis evaluating participants' current vs desired ability was performed after each trial. RESULTS From trial 1 to 3, there was a decrease in average procedural time by 31.7 minutes. The cumulative number of skipped steps and surgical errors decreased from 25 to 6 and 24 to 6, respectively. Overall surgical proficiency improved as indicated by video rating of efficiency and smoothness of surgical maneuvers, most notably with knowledge and handling of instruments. The greatest changes were noted in junior rather than senior residents. Average knowledge gap analysis significantly decreased by 30% from the first to last trial (P = .001), signifying trainees performed closer to their desired technical goal. CONCLUSION Procedural metrics for minimally invasive ULBD in combination with a realistic surgical simulator can be used to improve the skills and confidence of trainees. Surgical simulation may offer an important educational complement to traditional methods of skill acquisition and should be explored further with other MIS techniques.
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Affiliation(s)
- Carolin Melcher
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital Munich, Munich, Germany
| | - Ibrahim Hussain
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jacob L. Goldberg
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Fabian Sommer
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Branden Medary
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
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4
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Malik KN, Giberson C, Ballard M, Camp N, Chan J. Pain Management Interventions in Lumbar Spinal Stenosis: A Literature Review. Cureus 2023; 15:e44116. [PMID: 37753034 PMCID: PMC10518428 DOI: 10.7759/cureus.44116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Lumbar spinal stenosis (LSS) occurs due to the narrowing of the space within the vertebral canal and or intervertebral foramina. This results in the compression of the spinal cord and possibly the roots of the spinal nerves. Lower back pain and neurogenic claudication (NC) are major symptoms of spinal stenosis. This is a literature review that summarizes the important findings pertaining to pain management of spinal stenosis. Twenty-four original articles were assessed. Pain can be treated through non-invasive or surgical methods. Conservative techniques include physical exercises, epidural corticosteroid injection, local anesthetic injection therapy, and oral analgesics. Surgical intervention deals with the decompression of the affected spinal region, with or without vertebral fusion surgery. Other novel surgical techniques include implantation of specific equipment, known as interspinous spacer devices and minimally invasive lumbar decompression (MILD). Most studies offering a comparative analysis have demonstrated that surgical intervention is more efficacious than non-surgical interventions to manage pain associated with spinal stenosis.
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Affiliation(s)
- Kashif N Malik
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Curren Giberson
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Matthew Ballard
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Nathan Camp
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Justin Chan
- Physical Medicine and Rehabilitation, Western University of Health Sciences, Pomona, USA
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5
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Patel K, Son SM, Zhang Q, Wang JC, Buser Z. An Investigation Into the Relationship Between the Sedimentation Sign and Lumbar Disc Herniation in Upright Magnetic Resonance Images. Global Spine J 2023:21925682231170612. [PMID: 37081603 DOI: 10.1177/21925682231170612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
STUDY DESIGN Retrospective Upright MRI Study. OBJECTIVES Determine the relationship between lumbar disc herniation and presence of the nerve root sedimentation sign on upright kinematic MRI patients. METHODS T2-weighted axial upright kMRI images of 100 patients with the presence of disc herniation in at least 1 lumbar disc between L1/L2 and L5/S1 were obtained. Sedimentation sign, spinal canal anterior-posterior (AP) diameter, disc height, disc herniation size, type of herniation, and zone of herniation were evaluated. A positive sedimentation sign was defined as having either the majority of nerve roots running ventrally or centrally in the canal or conglomeration of the nerve roots at the mid-disc level. Herniation types were defined as either no herniation, disc bulge, protrusion, extrusion, or sequestration. Zones of herniation were categorized as either central, lateral, or far lateral. RESULTS The kappa value of intra-observer reliability was .915. The kappa value of disc levels with a negative sedimentation sign were seen more frequently (n = 326, 65.2%) than those with a positive sedimentation sign (n = 174, 34.8%). The spinal canal AP diameter was significantly decreased at the L3/L4 and L4/L5 level in patients with a positive sedimentation sign. Discs with a positive sedimentation sign had a larger average size of disc herniation compared to those with a negative sign at all levels. A relationship between positivity of the sedimentation sign and disc herniation type was significant at L2/L3, L3/L4, and L4/L5. CONCLUSIONS Patients with a positive sedimentation sign were seen to have larger disc herniations and more severely degenerated discs.
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Affiliation(s)
- Kishan Patel
- Department of Orthpaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Seung Min Son
- Department of Orthpaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Medical Research Institute, Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Republic of Korea
| | - Qiwen Zhang
- Department of Orthpaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Medical Research Institute, Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Republic of Korea
| | - Zorica Buser
- Department of Orthpaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Orthopaedic Surgery, Grossman School of Medicine, New York University, New York, NY, USA
- Gerling Institute, Brooklyn, NY, USA
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Darlow M, Suwak P, Sarkovich S, Williams J, Redlich N, D'Amore P, Bhandutia AK. A Pathway for the Diagnosis and Treatment of Lumbar Spinal Stenosis. Orthop Clin North Am 2022; 53:523-534. [PMID: 36208894 DOI: 10.1016/j.ocl.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Lumbar spinal stenosis is a prevalent condition with varied presentation. Most common in older populations, symptoms typically include back, buttock, and posterior thigh pain. Diagnosis is typically based on physical examination and clinical history, but confirmed on imaging studies. Nonsurgical management includes nonsteroidal anti-inflammatories, physical therapy, and epidural injections. If nonoperative management fails or patient presentation involves worsening symptoms, surgical intervention, most commonly in the form of a laminectomy, may be indicated. Recent literature has demonstrated improved pain and functional outcomes with surgery compared with conservative treatment in the middle to long term.
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Affiliation(s)
- Matthew Darlow
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA.
| | - Patrik Suwak
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Stefan Sarkovich
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Jestin Williams
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Nathan Redlich
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Peter D'Amore
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Amit K Bhandutia
- LSU-Orthopaedics, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
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7
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Rundell SD, Saito A, Meier EN, Danyluk ST, Jarvik JG, Seebeck K, Friedly JL, Heagerty PJ, Johnston SK, Smersh M, Horn ME, Suri P, Cizik AM, Goode AP. The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study. BMC Musculoskelet Disord 2022; 23:692. [PMID: 35864487 PMCID: PMC9306038 DOI: 10.1186/s12891-022-05598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS. Methods This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation. Discussion This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05598-x.
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Affiliation(s)
- Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Box 356490, 1959 NE Pacific St, Seattle, WA, 98195-6490, USA. .,Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA. .,Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.
| | - Ayumi Saito
- Department of Rehabilitation Medicine, University of Washington, Box 356490, 1959 NE Pacific St, Seattle, WA, 98195-6490, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Eric N Meier
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Jeffrey G Jarvik
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA.,Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA.,Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Kelley Seebeck
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Box 356490, 1959 NE Pacific St, Seattle, WA, 98195-6490, USA.,Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
| | - Patrick J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sandra K Johnston
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - Monica Smersh
- Department of Rehabilitation Medicine, University of Washington, Box 356490, 1959 NE Pacific St, Seattle, WA, 98195-6490, USA
| | - Maggie E Horn
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Pradeep Suri
- Department of Rehabilitation Medicine, University of Washington, Box 356490, 1959 NE Pacific St, Seattle, WA, 98195-6490, USA.,Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.,Division of Rehabilitation Care Services, Veteran Affairs Puget Sound Health Care System, Seattle, WA, USA.,Seattle Epidemiologic Research and Information Center, Veteran Affairs Puget Sound Health Care System,, Seattle, WA, USA
| | - Amy M Cizik
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Adam P Goode
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Canseco JA, Karamian BA, Minetos PD, Paziuk TM, Gabay A, Reyes AA, Bechay J, Xiao KB, Nourie BO, Kaye ID, Woods BI, Rihn JA, Kurd MF, Anderson DG, Hilibrand AS, Kepler CK, Schroeder GD, Vaccaro AR. Risk Factors for 30-day and 90-day Readmission After Lumbar Decompression. Spine (Phila Pa 1976) 2022; 47:672-679. [PMID: 35066538 DOI: 10.1097/brs.0000000000004325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess readmission rates and risk factors for 30-day and 90-day readmission after elective lumbar decompression at a single institution. SUMMARY OF BACKGROUND DATA Hospital readmission is an undesirable aspect of interventional treatment. Studies evaluating readmissions after elective lumbar decompression typically analyze national databases, and therefore have several drawbacks inherent to their macroscopic nature that limit their clinical utility. METHODS Patients undergoing primary one- to four-level lumbar decompression surgery were retrospectively identified. Demographic, surgical, and readmission data within "30-days" (0-30 days) and "90-days" (31-90 days) postoperatively were extracted from electronic medical records. Patients were categorized into four groups: (1) no readmission, (2) readmission during the 30-day or 90-day postoperative period, (3) complication related to surgery, and (4) Emergency Department (ED)/Observational (OBs)/Urgent (UC) care. RESULTS A total of 2635 patients were included. Seventy-six (2.9%) were readmitted at some point within the 30- (2.3%) or 90-day (0.3%) postoperative periods. Patients in the pooled readmitted group were older (63.1 yr, P < 0.001), had a higher American Society of Anesthesiologists (ASA) grade (31.2% with ASA of 3, P = 0.03), and more often had liver disease (8.1%, P = 0.004) or rheumatoid arthritis (12.0%, P = 0.02) than other cohorts. A greater proportion of 90-day readmissions and complications had surgical-related diagnoses or a diagnosis of recurrent disc herniation than 30-day readmissions and complications (66.7% vs. 44.5%, P = 0.04 and 33.3% vs. 5.5%, P < 0.001, respectively). Age (Odds ratio [OR]: 1.02, P = 0.01), current smoking status (OR: 2.38, P < 0.001), longer length of stay (OR: 1.14, P < 0.001), and a history of renal failure (OR: 2.59, P = 0.03) were independently associated with readmission or complication. CONCLUSION Increased age, current smoking status, hospital length of stay, and a history of renal failure were found to be significant independent predictors of inpatient readmission or complication after lumbar decompression.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Taylor M Paziuk
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alyssa Gabay
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Ariana A Reyes
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Joseph Bechay
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Kevin B Xiao
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Blake O Nourie
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - I David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Barrett I Woods
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark F Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - D Greg Anderson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Gregory D Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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9
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Moehl K, Newman D, Perera S, Toto PE, Weiner DK. Validating Goal Attainment in Veterans Undergoing Decompressive Laminectomy: A Preliminary Study. PAIN MEDICINE 2021; 22:829-835. [PMID: 33211875 DOI: 10.1093/pm/pnaa406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Although decompressive laminectomy (DL) for lumbar spinal stenosis (LSS) is a common procedure among older adults, it is unclear whether surgical definitions of success translate into patient-defined success. Using goal attainment scaling (GAS) to compare goal achievement between individuals, we investigated the relationship between surgical-defined functional recovery and achievement of personalized goals in patients who underwent DL for LSS. PARTICIPANTS Twenty-eight community-dwelling veterans scheduled to undergo DL. METHODS Participants were interviewed over the phone to set 1-year post-DL goals within 30 days before undergoing DL. Brigham Spinal Stenosis (BSS) score, comorbidities, cognitive function, and psychological factors also were assessed. GAS and BSS were repeated 1 year after DL. GAS scores were transformed into GAS-T scores (T-score transformation) to standardize achievement between patients and GAS-T change scores to compare study variables. RESULTS Seventeen of 28 participants had successful DL outcomes by BSS standards, though none of the participants achieved all of their GAS goals, with follow-up GAS-T scores averaging 44.5 ± 16.8. All three BSS scales positively correlated with GAS-T change scores: severity change r = 0.52, P = 0.005; physical function change r = 0.51, P = 0.006; and satisfaction r = 0.70, P < 0.001. Covariate analysis revealed a negative correlation between GAS-T change score and fear-avoidance beliefs: r = -0.41, P = -0.029. CONCLUSION There was congruent validity between GAS and the BSS in older veterans undergoing DL for LSS. Given the need for patient-centered care in older adults, future investigations exploring GAS in larger studies that target additional pain conditions and include participants with greater demographic diversity are warranted.
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Affiliation(s)
| | - Dave Newman
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Subashan Perera
- Department of Medicine (Geriatric Medicine).,Department of Biostatistics
| | | | - Debra K Weiner
- Department of Medicine (Geriatric Medicine).,Department of Psychiatry.,Department of Anesthesiology.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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10
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Identifying biopsychosocial factors that impact decompressive laminectomy outcomes in veterans with lumbar spinal stenosis: a prospective cohort study. Pain 2021; 162:835-845. [PMID: 32925594 DOI: 10.1097/j.pain.0000000000002072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
ABSTRACT One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.
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Krzanowska E, Liberacka D, Przewłocki R, Wordliczek J, Moskała M, Polak M, Zajączkowska R. The frequency and risk factors for surgery dissatisfaction in patients undergoing lumbar or cervical surgery for degenerative spinal conditions. PSYCHOL HEALTH MED 2020; 27:1084-1094. [PMID: 33320724 DOI: 10.1080/13548506.2020.1859562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study evaluated the frequency and risk factors for surgery dissatisfaction in patients undergoing lumbar or cervical surgery for degenerative spinal conditions. Based on the Patient Satisfaction Index (PSI) at 6 months after surgery, we divided patients into two groups: a satisfied and a dissatisfied group. We evaluated the association between patient dissatisfaction and five categories of variables:1) sociodemographic; 2) preoperative pain and disability [pain duration, level of surgery, previous spinal surgeries, pain scores as measured by the Short Form McGill Pain Questionnaire (SF-MPQ), numerical rating of average pain (NRS), disability as measured by the Oswestry Disability Index (ODI)]; 3) preoperative psychological status [depression, anxiety, and overall distress as measured by the Hospital Anxiety and Depression Scale (HADS), life satisfaction as measured by the Satisfaction With Life Scale (SWLS), and surgery expectations (SE) as measured by a Likert scale]; 4) postoperative improvements in pain and disability [improvements in SF-MPQ, improvement in ODI] and 5) postoperative psychological status [HADS, SWLS]. Results showed that 17.8% patients were dissatisfied with surgery. In the multivariate logistic analysis, more negative surgery expectations, smaller improvement in ODI scores, and a greater postoperative overall distress were significant risk factors associated with patient dissatisfaction with surgery.
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Affiliation(s)
- Eliza Krzanowska
- Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
| | - Donata Liberacka
- Faculty of Medicine, Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Ryszard Przewłocki
- Department of Molecular Neuropharmacology, Polish Academy of Science, Institute of Pharmacology, Kraków, Poland
| | - Jerzy Wordliczek
- Faculty of Medicine, Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Marek Moskała
- Faculty of Medicine, Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Polak
- Institute of Applied Psychology, Jagiellonian University, Kraków, Poland
| | - Renata Zajączkowska
- Faculty of Medicine, Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland
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Massel DH, Mayo BC, Narain AS, Hijji FY, Louie PK, Jenkins NW, Parrish JM, Singh K. Improvements in Back and Leg Pain Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion. Int J Spine Surg 2020; 14:745-755. [PMID: 33184122 DOI: 10.14444/7107] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Improvement in patient-reported outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is poorly defined. As such, the purpose of this study was to quantify improvements in Visual Analogue Scale back and leg pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12) Mental and Physical Composite scores following MIS-TLIF. METHODS A surgical registry of patients who underwent primary 1-level MIS-TLIF during 2014-2015 was reviewed. Comparisons of Visual Analogue Scale back and leg pain, ODI, and Short Form-12 Mental and Physical Composite scores were performed using paired t tests from preoperative to each postoperative time point. Analysis of variance was used to estimate the degree of improvement in back and leg pain over the first postoperative year. Subgroup analysis was performed for patients presenting with predominant back (pBP) or leg (pLP) pain. Multivariate linear regression was performed to compare patient-reported outcome scores by subgroup. RESULTS A total of 106 patients were identified. Visual Analogue Scale back and leg scores, and ODI improved from preoperative scores at all postoperative time points (P < .05 for each). Patients with pBP (n = 68) and patients with pLP (n = 38) reported reductions in both back and leg pain over the first postoperative year (P < .05 for each). In the pBP cohort, patients experienced significant reductions in ODI after the first 6 postoperative weeks (P < .05 for each). In the pLP cohort, patients experienced significant reductions in ODI throughout the first postoperative year (P < .05 for each). Patients with pLP and pBP experienced similar reductions in back pain, whereas patients with pLP experienced significantly greater reductions in leg pain at all postoperative time points (P < .05 for each). CONCLUSIONS The current study suggests patients experience significant improvements in back and leg pain following MIS-TLIF regardless of predominant symptom. CLINICAL RELEVANCE These results can assist surgeons when counseling their patients on the magnitude of symptom improvement they may experience following MIS-TLIF.
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Affiliation(s)
- Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Benjamin C Mayo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Philip K Louie
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Nicol AL, Adams MCB, Gordon DB, Mirza S, Dickerson D, Mackey S, Edwards D, Hurley RW. AAAPT Diagnostic Criteria for Acute Low Back Pain with and Without Lower Extremity Pain. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2661-2675. [PMID: 32914195 PMCID: PMC8453619 DOI: 10.1093/pm/pnaa239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain is one of the most common reasons for which people visit their doctor. Between 12% and 15% of the US population seek care for spine pain each year, with associated costs exceeding $200 billion. Up to 80% of adults will experience acute low back pain at some point in their lives. This staggering prevalence supports the need for increased research to support tailored clinical care of low back pain. This work proposes a multidimensional conceptual taxonomy. METHODS A multidisciplinary task force of the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) with clinical and research expertise performed a focused review and analysis, applying the AAAPT five-dimensional framework to acute low back pain. RESULTS Application of the AAAPT framework yielded the following: 1) Core Criteria: location, timing, and severity of acute low back pain were defined; 2) Common Features: character and expected trajectories were established in relevant subgroups, and common pain assessment tools were identified; 3) Modulating Factors: biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: domains of impact were outlined and defined; 5) Neurobiological Mechanisms: putative mechanisms were specified including nerve injury, inflammation, peripheral and central sensitization, and affective and social processing of acute low back pain. CONCLUSIONS The goal of applying the AAAPT taxonomy to acute low back pain is to improve its assessment through a defined evidence and consensus-driven structure. The criteria proposed will enable more rigorous meta-analyses and promote more generalizable studies of interindividual variation in acute low back pain and its potential underlying mechanisms.
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Affiliation(s)
- Andrea L Nicol
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Meredith C B Adams
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Debra B Gordon
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Sohail Mirza
- Department of Orthopedic Surgery, Geisel School of Medicine at Dartmouth University, Hanover, New Hampshire
| | - David Dickerson
- Department of Anesthesiology, NorthShore University Health System, Evanston, Illinois
| | - Sean Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - David Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston Salm, North Carolina, USA
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Predictive Value of Comprehensive Geriatric Assessment on Early Postoperative Complications Following Lumbar Spinal Stenosis Surgery: A Prospective Cohort Study. Spine (Phila Pa 1976) 2020; 45:1498-1505. [PMID: 32694487 DOI: 10.1097/brs.0000000000003597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim of this study was to evaluate the predictive value of comprehensive geriatric assessment (CGA) for early postoperative complications in elderly patients (aged 65 years or older) following lumbar spinal stenosis surgery. SUMMARY OF BACKGROUND DATA CGA is a multidisciplinary evaluation modality proven to be effective in various fields of geriatrics. However, limited evidence exists on the effectiveness of CGA in lumbar spinal stenosis patients in the literature. METHODS We prospectively enrolled consecutive patients who were at least 65 years' old and were scheduled to undergo elective surgery for lumbar spinal stenosis. One day before the operation, multidomain CGA was performed on the patient's functional status, comorbidities, nutrition, cognition, and psychological status. Patients with deficits in three or more CGA domains were defined as frail. The occurrence of postoperative complications (Clavien and Dindo grade 2 or higher) within 30 days after the surgery was assessed as the outcome. The predictive value of CGA was evaluated using crosstab and logistic regression analysis and compared to that of other risk stratification systems, including modified Frailty Index-5, -11, and American Society of Anesthesiologists Physical Classification System. RESULTS A total of 261 patients were included in the study, and 25 (9.6%) patients were assigned to the "frail" group. There were 27 (10.3%) patients with a postoperative complication (general: n = 20, 7.7%, surgical: n = 7, 2.7%) within postoperative 30 days. Patients with a complication showed significantly more deficits on preoperative CGA than those without complications (P = 0.004). On multivariate logistic regression analysis, frailty based on CGA (odds ratio = 3.51, P = 0.031) and the modified Frailty Index-11 (odds ratio = 3.13, P = 0.038) were associated with the occurrence of general complications. CONCLUSION Frailty based on CGA was significantly associated with early general complications following surgery for lumbar spinal stenosis in patients older than 65 years. LEVEL OF EVIDENCE 2.
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Jung JM, Hyun SJ, Kim KJ, Kim CH, Chung CK, Kim KH, Cho YE, Shin DA, Park YK, Choi Y. A prospective study of non-surgical versus surgical treatment for lumbar spinal stenosis without instability. J Clin Neurosci 2020; 80:100-107. [PMID: 33099329 DOI: 10.1016/j.jocn.2020.07.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/29/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youn-Kwan Park
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
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Jung JM, Chung CK, Kim CH, Choi Y, Kim MJ, Yim D, Yang SH, Lee CH, Hwang SH, Kim DH, Yoon JH, Park SB. The Long-term Reoperation Rate Following Surgery for Lumbar Stenosis: A Nationwide Sample Cohort Study With a 10-year Follow-up. Spine (Phila Pa 1976) 2020; 45:1277-1284. [PMID: 32355142 DOI: 10.1097/brs.0000000000003515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min-Jung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dahae Yim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Hyun Lee
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Hwan Hwang
- Department of Neurosurgery, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Dong Hwan Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joon Ho Yoon
- Department of Neurosurgery, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Boramae Hospital, Seoul, Republic of Korea
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Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial (SPORT) for Degenerative Spondylolisthesis. Spine (Phila Pa 1976) 2020; 45:820-824. [PMID: 32205705 DOI: 10.1097/brs.0000000000003485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We performed a comprehensive search of PubMed, MEDLINE, and EMBASE for all English language studies of all levels of evidence pertaining to Spine Patient Outcomes Research Trial (SPORT), in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. OBJECTIVE We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA The SPORT was a landmark randomized control trial including approximately 2500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS Keywords used in the literature search included SPORT, spine patient outcomes research trial, degenerative spondylolisthesis, and surgical outcomes. RESULTS The intent-to-treat analysis failed to show a significant difference between patients treated surgically as compared to those treated nonoperatively. However, as-treated analysis revealed statically greater improvements at 6 weeks, 2 years, and 4 years in patients treated surgically. Secondary outcomes such as low back pain, leg pain, stenosis bothersome scales, overall satisfaction with current symptoms, and self-rated progress were also significantly improved in surgical patients. Regardless of the initial grade of listhesis, disk height, or mobility, patients who had surgical treatment improved more in terms of Oswestry Disability Index, bodily pain, physical function, and low back pain bothersomeness scales. Risk of reoperation increased with age, having two or three moderate or severe stenotic levels, pain predominantly localized to the back, no physical therapy, the absence of neurogenic claudication, and greater leg pain scores. Risk of reoperation was not significantly affected by type of surgery performed, smoking, diabetes, obesity, longer duration of symptoms, or workman's compensation. CONCLUSION Although intent-to-treat analysis failed to show significant differences in patients treated surgically, results of the as-treated analysis determined statically greater improvements in those patients with spondylolisthesis who were treated surgically as compared to those treated nonoperatively. LEVEL OF EVIDENCE 2.
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Systematic Review of Outcomes Following 10-year Mark of Spine Patient Outcomes Research Trial (SPORT) for Spinal Stenosis. Spine (Phila Pa 1976) 2020; 45:832-836. [PMID: 31770345 DOI: 10.1097/brs.0000000000003323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for all English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analayses (PRISMA) guidelines. OBJECTIVE We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for spinal stenosis. SUMMARY OF BACKGROUND DATA The Spine Patient Outcomes Research Trial (SPORT) was a landmark randomized control trial including approximately 2,500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS Keywords utilized in the literature search included: SPORT, spine patient outcomes research trial, spinal stenosis, and surgical outcomes. RESULTS Surgical intervention showed significantly greater improvement in pain and physical function scales from 6 weeks through 4 years. However, between 4 and 8 years, the difference between the two groups diminished, and the benefits in both groups stabilized. Secondary factors investigated showed that smoking was a confounding variable for treatment benefits and a positive sedimentation sign correlated with a greater surgical treatment effect. Obese patients were found to have higher rates of infection and reoperation and less improvement from baseline function. Risk factors for reoperation included duration of pretreatment symptoms for longer than 12 months, increased age, multiple levels of stenosis, predominant back pain, no physical therapy, greater leg pain, the use of antidepressants and no neurogenic claudication upon enrollment. CONCLUSION Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of spinal stenosis. Results showed significantly greater improvement through 4 year follow up in those patients that received surgical treatment, however the difference between the surgical and nonsurgical groups diminished at 8 year follow up. LEVEL OF EVIDENCE 3.
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Carrascosa-Granada A, Velazquez W, Wagner R, Saab Mazzei A, Vargas-Jimenez A, Jorquera M, Albacar JAB, Sallabanda K. Comparative Study Between Uniportal Full-Endoscopic Interlaminar and Tubular Approach in the Treatment of Lumbar Spinal Stenosis: A Pilot Study. Global Spine J 2020; 10:70S-78S. [PMID: 32528810 PMCID: PMC7263328 DOI: 10.1177/2192568219878419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Multicenter, prospective, randomized, and double-blinded study. OBJECTIVES To compare tubular and endoscopic interlaminar approach. METHODS Patients with lumbar spinal stenosis and neurogenic claudication of were randomized to tubular or endoscopic technique. Enrollment period was 12 months. Clinical follow up at 1, 3, 6 months after surgery with visual analogue scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) score. Radiologic evaluation with magnetic resonance pre- and postsurgery. RESULTS Twenty patients were enrolled: 10 in tubular approach (12 levels) and 10 in endoscopic approach (11 levels). The percentage of enlargement of the spinal canal was higher in endoscopic approach (202%) compared with tubular approach (189%) but was not statistically significant (P = .777). The enlargement of the dural sac was higher in endoscopic group (209%) compared with tubular group (203%) but no difference was found between the 2 groups (P = .628). A modest significant correlation was found between the percentage of spinal canal decompression and enlargement of the dural sac (r = 0.5, P = .023). Both groups reported a significant clinical improvement postsurgery. However, no significant association was found between the percentage of enlargement of the spinal canal or the dural sac and clinical improvement as determined by scales scores. Endoscopic group had lower intrasurgical bleeding (P < .001) and lower disability at 6 months of follow-up than tubular group (p=0.037). CONCLUSIONS In the treatment of lumbar spinal stenosis, endoscopic technique allows similar decompression of the spinal canal and the dural sac, lower intrasurgical bleeding, similar symptoms improvement, and lower disability at 6 months of follow-up, as compared with the tubular technique.
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Affiliation(s)
| | | | | | | | | | | | | | - Kita Sallabanda
- Hospital Clínico San Carlos, Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
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21
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Markman JD, Czerniecka-Foxx K, Khalsa PS, Hayek SM, Asher AL, Loeser JD, Chou R. AAPT Diagnostic Criteria for Chronic Low Back Pain. THE JOURNAL OF PAIN 2020; 21:1138-1148. [PMID: 32036046 DOI: 10.1016/j.jpain.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
Chronic low back pain (CLBP) conditions are highly prevalent and constitute the leading cause of disability worldwide. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS), have combined to create the ACTTION-APS Pain Taxonomy (AAPT). The AAPT initiative convened a working group to develop diagnostic criteria for CLBP. The working group identified 3 distinct low back pain conditions which result in a vast public health burden across the lifespan. This article focuses on: 1) the axial predominant syndrome of chronic musculoskeletal low back pain, 2) the lateralized, distally-radiating syndrome of chronic lumbosacral radicular pain 3) and neurogenic claudication associated with lumbar spinal stenosis. This classification of CLBP is organized according to the AAPT multidimensional framework, specifically 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. PERSPECTIVE: An evidence-based classification of CLBP conditions was constructed for the AAPT initiative. This multidimensional diagnostic framework includes: 1) core diagnostic criteria; 2) common features; 3) medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester, Rochester, New York.
| | | | - Partap S Khalsa
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Salim Michel Hayek
- Division of Pain Medicine, Department of Anesthesiology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Atrium Health, Charlotte, North Carolina
| | - John D Loeser
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
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Improvements in Back and Leg Pain After Minimally Invasive Lumbar Decompression. HSS J 2020; 16:62-71. [PMID: 32015742 PMCID: PMC6973967 DOI: 10.1007/s11420-018-09661-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have quantified clinical improvement following minimally invasive lumbar decompression based on predominant back pain or leg pain. PURPOSE To quantify improvement in patient-reported outcomes following minimally invasive lumbar decompression and determine the degree of improvement in back pain, leg pain, and disability in patients who present with predominant back pain or predominant leg pain. METHODS Patients who underwent primary, one-level minimally invasive lumbar decompression for degenerative pathology were retrospectively reviewed. Comparisons of visual analog scale (VAS) back and leg pain scores, Oswestry Disability Index (ODI) scores, and Short Form-12 (SF-12) mental and physical component scores from pre-operative to 6-week, 12-week, 6-month, and 1-year follow-up. Subgroup analyses were performed for patients with predominant back pain or predominant leg pain. RESULTS A total of 102 patients were identified. Scores on VAS back and leg pain, ODI, and SF-12 physical component improved from pre-operative to all post-operative time points. After 1 year, patients reported a 2.8-point (47%) reduction in back pain and a 4-point (61.1%) reduction in leg pain scores; 52 patients with predominant back pain and 50 patients with predominant leg pain reported reductions in pain throughout the year following surgery. In both the back and leg pain cohorts, patients experienced reductions in ODI during the first 6 months and throughout 1-year follow-up, respectively. The majority of patients achieved minimum clinically important difference, regardless of predominant symptom. CONCLUSIONS Patients reported improvements in back and leg pain following minimally invasive lumbar decompression regardless of predominant presenting symptom; however, patients with predominant leg pain may experience greater improvement than those with predominant back pain.
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Yue B, Shen F, Ye ZF, Wang ZH, Yang HL, Jiang GQ. Accurate location and minimally invasive treatment of lumbar lateral recess stenosis with combined SNRB and PTED. J Int Med Res 2019; 48:300060519884817. [PMID: 31774009 PMCID: PMC7607284 DOI: 10.1177/0300060519884817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To establish a management strategy for multi-segment lumbar lateral recess stenosis. METHODS A retrospective study was performed in patients in whom suspected responsible nerve roots underwent sequential selective nerve root block (SNRB). Based on pain remission rate after blocking, the contribution of nerve root compression to symptoms was classified as absolutely (≥70%) or relatively (30-70%) responsible or non-responsible (<30%). Conservative treatment was continued if visual analogue scale (VAS) at 3 days after blocking a single nerve root or VAS at 3 days after blocking multiple nerve roots was ≥50%; otherwise, percutaneous transforaminal endoscopic discectomy (PTED) was performed. Pain and functional scores were evaluated on day 3, 6 months and 1 year after SNRB or PTED. RESULTS Fifty-seven of 80 patients had a single absolutely responsible root, 20 had 2 responsible roots, and 3 had 3 responsible roots. Among them, 41, 10, and 1 patient underwent PTED, respectively. Both the PTED and conservative groups improved significantly in VAS remission rate and functional scores compared with admission. Moreover, the PTED group had a better VAS remission rate compared with the conservative group. CONCLUSION A combination of SNRB with PTED was effective for diagnosing and treating multi-segment lumbar lateral recess stenosis.
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Affiliation(s)
- Bing Yue
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, Soochow, PR China
| | - Fang Shen
- Department of Spine, the Affiliated Hospital of Medical School of Ningbo University, Ningbo, PR China
| | - Zhi-Fang Ye
- Department of Spine, the Affiliated Hospital of Medical School of Ningbo University, Ningbo, PR China
| | - Ze-Hao Wang
- Department of Spine, the Affiliated Hospital of Medical School of Ningbo University, Ningbo, PR China
| | - Hui-Lin Yang
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, Soochow, PR China
| | - Guo-Qiang Jiang
- Department of Spine, the Affiliated Hospital of Medical School of Ningbo University, Ningbo, PR China
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24
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Bello F, Njami VA, Bogne SL, Lekane NA, Mbele GI, Nchufor R, Ndome OL, Haman ON, Djientcheu VDP. Quality of life of patients operated for lumbar stenosis at the Yaoundé Central Hospital. Br J Neurosurg 2019; 34:62-65. [PMID: 31747796 DOI: 10.1080/02688697.2019.1692784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Several studies have been conducted in many African countries on lumbar stenosis but none on the quality of life of patients after surgery. We conducted this study to evaluate the quality of life of patients following surgery indicated for lumbar stenosis.Methods: A cross-sectional study from January 2010 to December 2015 in the neurosurgery department of the Yaoundé Central Hospital. We included all patients operated for lumbar stenosis, whose post-operative follow-up was at least of one year. Sampling was consecutive using operating room registries and archives of the neurosurgery department. We used the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) to evaluate patient's quality of life.Results: We recruited 52 patients. The mean age was 58.13 years. Pre-operatively, 67.3% of patients presented with severe pain (mean VAS of 8.9). At 3 months, 59.6% presented with moderate pain (mean VAS = 4.75). At six months following surgery, 92.3% of patients had mild pain (mean VAS = 2.92). At one year, all patients had only mild pain (mean VAS = 1.05). Pre-operatively, 67.30% of patients presented with severe walking disability; the mean ODI was 77.88% and a third were bedridden. Three months after surgery 61.50% presented with moderate disability and the mean ODI was 38.17%. Six months following surgery, 48.10% of patients presented with moderate disability and 42.30% presented with a mild disability (the mean ODI was 24.80%). At one year, 82% of patients presented with mild disability and the mean ODI was 12.67%.Conclusion: Surgery improved the physical condition of patients.
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Affiliation(s)
- F Bello
- Neurosurgery department, Yaoundé Central Hospital, Yaoundé, Cameroon.,Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - V A Njami
- Neurosurgery department, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - S L Bogne
- Higher Institute of Health Sciences, Université des Montagnes, Bangangté, Cameroon
| | - N A Lekane
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - G I Mbele
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - R Nchufor
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - O L Ndome
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - O N Haman
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - V de P Djientcheu
- Neurosurgery department, Yaoundé Central Hospital, Yaoundé, Cameroon.,Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon.,Higher Institute of Health Sciences, Université des Montagnes, Bangangté, Cameroon
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25
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Effect of spinal decompression on back pain in lumbar spinal stenosis: a Canadian Spine Outcomes Research Network (CSORN) study. Spine J 2019; 19:1001-1008. [PMID: 30664950 DOI: 10.1016/j.spinee.2019.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/12/2019] [Accepted: 01/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical decompression is usually offered for improvement of neurogenic claudication in patients with symptomatic lumbar canal stenosis. These patients often have associated low back pain (LBP) and little is known about the effect of decompression on this symptom. PURPOSE The goal of the present study is to specifically quantify the improvement in LBP following surgical decompression for lumbar canal stenosis and to identify factors associated with changes in LBP in this population. STUDY DESIGN This is a multicenter, retrospective review of consecutive spine surgery patients enrolled by the Canadian Spine Outcomes and Research Network. PATIENT SAMPLE Consecutive patients who underwent surgical treatment for symptomatic lumbar spine stenosis without instability between 2014 and 2017. OUTCOME MEASURES Change in LBP on the Numeric Rating Scale (NRS). METHODS Patient-reported outcomes were collected at baseline and at 3, 12, and 24 months after surgery. The primary outcome was change in LBP on the NRS. Multivariable logistic regression was used to model the relationship between the outcome and potential factors associated with achieving minimal clinical important difference in back pain using a backward selection procedure. RESULTS In all, 1,221 patients were included in the analysis. Mean age was 64 years and 58% were males. Baseline back pain scores were available in 1,133 patients and follow-up evaluations were available in 968/1,133 (85%) patients at 3 months, 649/903 (72%) patients at 12 months, and 331/454 (73%) at 24 months. LBP significantly improved 3 months after surgery and the improvement was sustained at 24 months (p<.001). We found that 74% of patients reached the minimal clinical important difference in back pain. Predictive factors for sustained improvement (12 and 24 months) in LBP after surgical intervention were absence of narcotic usage or compensation claims and increased severity of LBP before surgery (high NRS). CONCLUSIONS Alleviation of clinically significant LBP was observed at 3 months after lumbar decompression surgery for neurogenic claudication and was maintained at 12 and 24 months after surgery in the majority of patients.
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26
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Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial. Arch Phys Med Rehabil 2019; 100:797-810. [DOI: 10.1016/j.apmr.2018.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/29/2018] [Accepted: 12/01/2018] [Indexed: 12/15/2022]
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27
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Stienen MN, Maldaner N, Joswig H, Corniola MV, Bellut D, Prömmel P, Regli L, Weyerbrock A, Schaller K, Gautschi OP. Objective functional assessment using the “Timed Up and Go” test in patients with lumbar spinal stenosis. Neurosurg Focus 2019; 46:E4. [DOI: 10.3171/2019.2.focus18618] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPatient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the “Timed Up and Go” (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).METHODSA prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.RESULTSSixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.CONCLUSIONSThe TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.
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Affiliation(s)
- Martin N. Stienen
- 1Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich
| | | | - Holger Joswig
- 3Department of Clinical Neuroscience, Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva; and
| | - Marco V. Corniola
- 3Department of Clinical Neuroscience, Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva; and
| | - David Bellut
- 1Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich
| | - Peter Prömmel
- 2Department of Neurosurgery, Cantonal Hospital St. Gallen
| | - Luca Regli
- 1Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich
| | | | - Karl Schaller
- 3Department of Clinical Neuroscience, Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva; and
| | - Oliver P. Gautschi
- 3Department of Clinical Neuroscience, Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva; and
- 4Neuro- and Spine Center, Hirslanden Clinic St. Anna, Lucerne, Switzerland
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28
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Held U, Steurer J, Pichierri G, Wertli MM, Farshad M, Brunner F, Guggenberger R, Porchet F, Fekete TF, Schmid UD, Gravestock I, Burgstaller JM. What is the treatment effect of surgery compared with nonoperative treatment in patients with lumbar spinal stenosis at 1-year follow-up? J Neurosurg Spine 2019; 31:185-193. [PMID: 30952135 DOI: 10.3171/2019.1.spine181098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to obtain an unbiased causal treatment estimate of the between-group difference of surgery versus nonoperative treatment with respect to outcomes on quality of life, pain, and disability in patients with degenerative lumbar spinal stenosis (DLSS) 12 months after baseline. METHODS The authors included DLSS patients from a large prospective multicenter observational cohort study. Propensity score matching was used, including 15 demographic, clinical, and MRI variables. Linear and logistic mixed-effects regression models were applied to quantify the between-group treatment effect. Unmeasured confounding was addressed in a sensitivity analysis, assessing the robustness of the results. RESULTS A total of 408 patients were included in this study, 222 patients after matching, with 111 in each treatment group. Patients with nonoperative treatment had lower quality of life at the 12-month follow-up (-6.21 points, 95% CI -9.93 to -2.49) as well as lower chances of reaching a minimal clinically important difference in Spinal Stenosis Measure (SSM) symptoms (OR 0.26, 95% CI 0.13 to 0.53) and SSM function (OR 0.26, 95% CI 0.14 to 0.49), than patients undergoing surgery. These results were very robust in case of unmeasured confounding. The surgical complication rate was low; 5 (4.5%) patients experienced a durotomy during intervention, and 5 (4.5%) patients underwent re-decompression. CONCLUSIONS The authors used propensity score matching to assess the difference in treatment efficacy of surgery compared with nonoperative treatment in elderly patients with DLSS. This study delivers strong evidence that surgical treatment is superior to nonoperative treatment. It helps in clinical decision-making, especially when patients suffer for a long time, sometimes over many years, hoping for a spontaneous improvement of their symptoms. In light of these new results, the number of years with disability can hopefully be reduced by providing adequate treatment at the right time for this ever-growing elderly and frail population.
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Affiliation(s)
- Ulrike Held
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
- 2Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich
| | - Johann Steurer
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
| | - Giuseppe Pichierri
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
| | - Maria M Wertli
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
- 3Division of General Internal Medicine, Bern University Hospital, Bern University, Bern
| | - Mazda Farshad
- 4Spine Division, Balgrist University Hospital, Zurich
| | - Florian Brunner
- 5Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich
| | - Roman Guggenberger
- 6Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich
| | - François Porchet
- 7Spine Unit, Department of Orthopedic Surgery and Neurosurgery, Schulthess Clinic, Zurich; and
| | - Tamás F Fekete
- 7Spine Unit, Department of Orthopedic Surgery and Neurosurgery, Schulthess Clinic, Zurich; and
| | - Urs D Schmid
- 8Department of Neurosurgery, Stadtspital Triemli, Zurich, Switzerland
| | - Isaac Gravestock
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
| | - Jakob M Burgstaller
- 1Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich
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29
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Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits: The Impact of Surgical Timing on Functional Outcome. Spine (Phila Pa 1976) 2019; 44:454-463. [PMID: 28658038 DOI: 10.1097/brs.0000000000002295] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of the study was to assess the impact of time to surgery in patients with motor deficits (MDs) on their functional outcome. The current single-center study presents results of emergency surgery for LDH in a group of patients with acute paresis in a "real-world" setting. SUMMARY OF BACKGROUND DATA MDs are a frequent symptom of lumbar disc herniation (LDH). Although surgery within 48 hours has been recommended for cauda-equina syndrome, the best timing of surgery for acute MDs continues to be debated. The effect of early surgery has been proposed but remains to be unproven. METHODS A total of 330 patients with acute paresis caused by LDH acutely referred to our department and surgically treated using microsurgical discectomy from January 2013 to December 2015 were included. Based on the duration of MD and surgical timing, all patients were classified into two categories: Group I included all patients with paresis <48 hours and Group II included all patients with paresis >48 hours. Patient demographics, LDH/clinical/treatment characteristics, and outcomes were collected prospectively.Severity of paresis [Medical Research Council (MRC) Grade 0-4], surgery-related complications, functional recovery of motor/sensory deficits, sciatica, retreatment/recurrence rates, and overall neurological outcome were analyzed. RESULTS Group I showed significantly faster recovery of moderate/severe paresis (MRC 0-3) at discharge, and 6-weeks/3-months follow up (P ≤ 0.001), whereas there were no significant differences in recovery for mild paresis (MRC 4). Sensory deficits also recovered substantially faster in Group I at 6-weeks (P = 0.003) and 3-months follow up (P = 0.045). Body mass index, preoperative MRC-grade, and duration of MDs were identified as significant predictors for recovery of paresis at all follow ups with substantial impact on patient reported outcomes including sciatica and/or dermatomal sensory deficits. CONCLUSION Given the superior rates of neurological recovery of acute moderate/severe MDs, immediate surgery should be the primary option. However, a prospective randomized clinical trial is needed to confirm the superiority of emergency surgery. LEVEL OF EVIDENCE 3.
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30
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Pieters TA, Li YI, Towner JE, Schmidt T, Vates GE, Pilcher W, Li YM. Comparative Analysis of Decompression Versus Decompression and Fusion for Surgical Management of Lumbar Spondylolisthesis. World Neurosurg 2019; 125:e1183-e1188. [PMID: 30794979 DOI: 10.1016/j.wneu.2019.01.275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE When lumbar stenosis involves spondylolisthesis, many surgeons include fixation. Two recent trials have shown no consensus to definitive treatment. We aimed to add to the discourse of fusion versus decompression in patients with lumbar spondylolisthesis by providing a large-scale generalizable study. METHODS We used multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database to compare 30-day outcomes for decompression alone versus combination decompression and fusion in the treatment of lumbar spondylolisthesis. Logistic regression models were used to analyze the effect of surgical type on multiple characteristics. Univariate 2-tailed χ2 analyses were used to identify further outcome differences. RESULTS In total, 9606 patients with treated lumbar spondylolisthesis were identified (907 decompression only, 8699 decompression and fusion). The fusion group tended to be younger (P < 0.001) and was more likely to be smokers (P = 0.01). Unplanned return to surgery was 3.02% in the fusion group, compared with 1.02% (P = 0.011). Minor adverse events occurred in 12.8% of the fusion group versus 4.9% (P < 0.001). Major adverse events occurred in 4.5% of the fusion group versus 3.1% (P = 0.0498). There was no significant difference in 30-day mortality, prolonged admission, or 30-day readmission. CONCLUSIONS Unplanned return to the operating room and major and minor adverse events were greater for patients undergoing fusion. This could influence future decision-making in lumbar spondylolisthesis. This study indicates that further investigation is warranted but that decompression may be associated with less morbidity in the properly selected patient.
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Affiliation(s)
- Thomas A Pieters
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Yan Icy Li
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Bioinformatics, Nanjing Medical University, Nanjing, China
| | - James E Towner
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tyler Schmidt
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Yan Michael Li
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA.
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Long-Term Results of Surgery Compared With Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2018; 43:1619-1630. [PMID: 29652786 PMCID: PMC6185822 DOI: 10.1097/brs.0000000000002682] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized trial with a concurrent observational cohort study. OBJECTIVE To compare 8-year outcomes between surgery and nonoperative care and among different fusion techniques for symptomatic lumbar degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA Surgical treatment of DS has been shown to be more effective than nonoperative treatment out to 4 years. This study sought to further determine the long-term (8-year) outcomes. METHODS Surgical candidates with DS from 13 centers with at least 12 weeks of symptoms and confirmatory imaging were offered enrollment in a randomized controlled trial (RCT) or observational cohort study (OBS). Treatment consisted of standard decompressive laminectomy (with or without fusion) versus standard nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and yearly up to 8 years. RESULTS Data were obtained for 69% of the randomized cohort and 57% of the observational cohort at the 8-year follow up. Intent-to-treat analyses of the randomized group were limited by high levels of nonadherence to the randomized treatment. As-treated analyses in the randomized and observational groups showed significantly greater improvement in the surgery group on all primary outcome measures at all time points through 8 years. Outcomes were similar among patients treated with uninstrumented posterolateral fusion, instrumented posterolateral fusion, and 360° fusion. CONCLUSION For patients with symptomatic DS, patients who received surgery had significantly greater improvements in pain and function compared with nonoperative treatment through 8 years of follow-up. Fusion technique did not affect outcomes. LEVEL OF EVIDENCE 1.
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Loske S, Nüesch C, Byrnes KS, Fiebig O, Schären S, Mündermann A, Netzer C. Decompression surgery improves gait quality in patients with symptomatic lumbar spinal stenosis. Spine J 2018; 18:2195-2204. [PMID: 29709554 DOI: 10.1016/j.spinee.2018.04.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT We aimed to fully understand the extent of limitations associated with symptomatic lumbar spinal stenosis (LSS) and the functional outcome of its treatment, including not only function during daily activities (eg, using the 6-minute walk test [6MWT]) but also the quality of function that should be objectively assessed. PURPOSE This study was performed to test the hypothesis that the Oswestry Disability Index (ODI) score, the walking distance during the 6MWT (6-minute walking distance [6MWD]), and gait quality (spatiotemporal parameters and gait asymmetry) will improve postoperatively and achieve normal values; to determine if changes in gait parameters correlate with changes in Oswestry Disability Index (ODI) score; and to ascertain if patients' gait quality will diminish during the 6MWT, reflected by changes in gait parameters during the 6MWT. STUDY DESIGN/SETTING This is a prospective observational study with intervention. PATIENT SAMPLE The sample comprised patients with symptomatic LSS. OUTCOME MEASURES The ODI score, gait quality (spatiotemporal and asymmetry), and walking performance (walking distance during the 6MWT) were the outcome measures. METHODS Patients with symptomatic LSS were analyzed on the day before surgery and 10 weeks and 12 months postoperatively. Functional disability in daily life was assessed by the ODI. Spatiotemporal and kinematic gait parameters were recorded with an inertial sensor system during the 6MWT, and the 6MWD was determined. Gait asymmetry was defined as 100*|right-left|/(0.5*(|right+left|)). RESULTS The ODI decreased by 17.9% and 23.9% and 6MWD increased by 21 m and 26 m from baseline to 10-week and 12-month follow-up, respectively. Gait quality did not change during the 6MWT at any assessment or between assessments. Compared with the control group, patients walked less during the 6MWT, and gait quality differed between patients and the control group at baseline and 10-week follow-up but not at 12-month follow-up. Change in gait quality explained 39% and 73% of variance in change in ODI from baseline to 10-week and to 12-month follow-up, respectively. CONCLUSIONS Changes in gait quality explained a large portion of variance in changes in the ODI, indicating that patients with symptomatic LSS perceive their compromised gait quality as functional limitations. Gait data obtained by instrumented gait analysis contain information on gait quality that can be helpful for evaluating functional limitations in patients with LSS, the outcome of decompression surgery, and the development of patient-specific rehabilitation regimens.
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Affiliation(s)
- Stefan Loske
- Spine Surgery, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland; Clinic of Orthopaedics and Traumatology, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Corina Nüesch
- Clinic of Orthopaedics and Traumatology, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland; Department of Clinical Research, University of Basel, Spitalstrasse 21, Basel, 4031, Switzerland; Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, Allschwil, 4123, Switzerland
| | - Kimberly Sara Byrnes
- Clinic of Orthopaedics and Traumatology, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Oliver Fiebig
- Spine Surgery, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Stefan Schären
- Spine Surgery, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Annegret Mündermann
- Clinic of Orthopaedics and Traumatology, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland; Department of Clinical Research, University of Basel, Spitalstrasse 21, Basel, 4031, Switzerland; Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, Allschwil, 4123, Switzerland.
| | - Cordula Netzer
- Spine Surgery, University of Basel Hospital, Spitalstrasse 21, Basel, 4031, Switzerland
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Lim KT, Nam HGW, Kim SB, Kim HS, Park JS, Park CK. Therapeutic Feasibility of Full Endoscopic Decompression in One- to Three-Level Lumbar Canal Stenosis via a Single Skin Port Using a New Endoscopic System, Percutaneous Stenoscopic Lumbar Decompression. Asian Spine J 2018; 13:272-282. [PMID: 30472819 PMCID: PMC6454282 DOI: 10.31616/asj.2018.0228] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 10/07/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN This retrospective study involved 450 consecutive cases of degenerative lumbar stenosis treated with percutaneous stenoscopic lumbar decompression (PSLD). PURPOSE We determined the feasibility of PSLD for lumbar stenosis at single and multiple levels (minimum 1-year follow-up) by image analysis to observe postoperative widening of the vertebral canal in the area. OVERVIEW OF LITERATURE The decision not to perform an endoscopic decompression might be due to the surgeon being uncomfortable with conventional microscopic decompression or unfamiliar with endoscopic techniques or the unavailability of relevant surgical tools to completely decompress the spinal stenosis. METHODS The decompressed canal was compared between preoperative controls and postoperative treated cases. Data on operative results, including length of stay, operative time, and surgical complications, were analyzed. Patients were assessed clinically on the basis of the Visual Analog Scale (VAS) score for the back and legs and using the Oswestry Disability Index (ODI). RESULTS Postoperative magnetic resonance imaging revealed that PSLD increased the canal cross-sectional area by 52.0% compared with the preoperative area at the index segment (p<0.001) and demonstrated minimal damage to the normal soft tissues including muscles and the extent of removed normal bony tissues. Mean improvements in VAS score and ODI were 4.0 (p<0.001) and 40% (p<0.001), respectively. CONCLUSIONS PSLD could be an alternative to microscopic or microendoscopic decompression with various advantages in the surgical management of lumbar stenosis.
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Affiliation(s)
- Kang Taek Lim
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
| | - Han Ga Wi Nam
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
| | - Soo Beom Kim
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
| | - Hyung Suk Kim
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
| | - Jin Soo Park
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
| | - Chun-Kun Park
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, Korea
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Discriminant Ability, Concurrent Validity, and Responsiveness of PROMIS Health Domains Among Patients With Lumbar Degenerative Disease Undergoing Decompression With or Without Arthrodesis. Spine (Phila Pa 1976) 2018; 43:1512-1520. [PMID: 29621093 DOI: 10.1097/brs.0000000000002661] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective cohort study. OBJECTIVE The aim of this study was to investigate the ability of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains to discriminate between levels of disease severity and to determine the concurrent validity and responsiveness of PROMIS relative to "legacy" measures. SUMMARY OF BACKGROUND DATA PROMIS may measure recovery after lumbar spine surgery. Concurrent validity and responsiveness have not been compared with legacy measures in this population. METHODS We included 231 adults undergoing surgery for lumbar degenerative disease. Discriminant ability of PROMIS was estimated for adjacent categories of disease severity using the Oswestry Disability Index (ODI). Concurrent validity was determined through correlation between preoperative legacy measures and PROMIS. Responsiveness was estimated using distribution-based and anchor-based criteria (change from preoperatively to within 3 months postoperatively) anchored to treatment expectations (North American Spine Society Patient Satisfaction Index) to determine minimal important differences (MIDs). Significance was accepted at P < 0.05. RESULTS PROMIS discriminated between disease severity levels, with mean differences between adjacent categories of 3 to 8 points. There were strong to very strong correlations between Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, and PROMIS anxiety, depression, fatigue, and sleep disturbance; between ODI and PROMIS fatigue, pain, and physical function; between the 12-Item Short-Form Health Survey physical component and PROMIS pain and physical function; and between the Brief Pain Inventory (BPI) pain interference and PROMIS depression and pain. BPI back pain and leg pain intensity showed weak or no correlation with PROMIS. Distribution-based MIDs ranged from 3.0 to 3.5 points. After incorporating longitudinal anchor-based estimates, final PROMIS MID estimates were anxiety, -4.4; depression, -6.0; fatigue, -5.3; pain, -5.4; physical function, 5.2; satisfaction with participation in social roles, 6.0; and sleep disturbance, -6.5. CONCLUSION PROMIS discriminated between disease severity levels, demonstrated good concurrent validity, and was responsive to changes after lumbar spine surgery. LEVEL OF EVIDENCE 2.
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Hendrickson NR, Kelly MP, Ghogawala Z, Pugely AJ. Operative Management of Degenerative Spondylolisthesis. JBJS Rev 2018; 6:e4. [DOI: 10.2106/jbjs.rvw.17.00181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Can Early Patient-reported Outcomes Be Used to Identify Patients at Risk for Poor 1-Year Health Outcomes After Lumbar Laminectomy With Arthrodesis? Spine (Phila Pa 1976) 2018; 43:1067-1073. [PMID: 29215506 DOI: 10.1097/brs.0000000000002522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVE Determine A) between-patient variability in patient-reported outcomes (PROs) at four postoperative time points; B) within-patient correlation of 1-year PROs with PROs at three earlier time points; and C) ability of early PROs to predict 1-year PROs after lumbar laminectomy with arthrodesis. SUMMARY OF BACKGROUND DATA It is unclear whether early PROs can help identify patients at risk for poor health outcomes. METHODS Between 2015 and 2016, we assessed pre- and postoperative back pain, leg pain, disability, physical health, and mental health in 146 patients. We examined PRO variability between patients and correlations within patients during the first postoperative year. For early (≤3-mo) and 1-year PROs, we examined concordance between experiencing a minimal important difference (MID) early and at 1 year and odds of experiencing a 1-year MID given early absence of a MID. RESULTS Postoperatively, we found increasing between-patient variability of PROs. For individual patients, we found moderate to strong between-assessment correlations (intraclass correlations) between repeated PROs (back pain, 0.47; leg pain, 0.51; disability, 0.47; physical health, 0.63; mental health, 0.53). Early MIDs were experienced for back pain (57%), leg pain (52%), physical health (38%), disability (34%), and mental health (16%). Concordance was moderate for leg pain (0.48), mental health (0.46), disability (0.38), back pain (0.36), and physical health (0.25). In patients without an early MID, odds of experiencing a MID at 1 year were low for physical health (odds ratio [OR] = 0.33), back pain (OR = 0.30), leg pain (OR = 0.14), and disability (OR = 0.11) but not mental health (OR = 0.50). CONCLUSION Although postoperative recovery is variable, early PROs can identify patients at risk for poor 1-year outcomes and may help tailor care during the first year after lumbar laminectomy with arthrodesis. LEVEL OF EVIDENCE 2.
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Ammendolia C, Côté P, Southerst D, Schneider M, Budgell B, Bombardier C, Hawker G, Rampersaud YR. Comprehensive Nonsurgical Treatment Versus Self-directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial. Arch Phys Med Rehabil 2018; 99:2408-2419.e2. [PMID: 29935152 DOI: 10.1016/j.apmr.2018.05.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the effectiveness of a comprehensive nonsurgical training program to a self-directed approach in improving walking ability in lumbar spinal stenosis (LSS). DESIGN Randomized controlled trial. SETTING Academic hospital outpatient clinic. PARTICIPANTS Participants (N=104) with neurogenic claudication and imaging confirmed LSS were randomized. The mean age was 70.6 years, 57% were women, 84% had leg symptoms for >12 months, and the mean maximum walking capacity was 328.7 m. INTERVENTIONS A 6-week structured comprehensive training program or a 6-week self-directed program. MAIN OUTCOME MEASURES Continuous walking distance in meters measured by the Self-Paced Walk Test (SPWT) and proportion of participants achieving at least 30% improvement (minimally clinically important difference [MCID]) in the SPWT at 6 months. Secondary outcomes included the Zurich Claudication Questionnaire (ZCQ), Oswestry Disability Index (ODI), ODI walk score, and the Short-Form General Health Survey subscales. RESULTS A total of 48 versus 51 participants who were randomized to comprehensive (n=51) or self-directed (n=53) treatment, respectively, received the intervention and 89% of the total study sample completed the study. At 6 months, the adjusted mean difference in walking distance from baseline was 421.0 m (95% confidence interval [95% CI], 181.4-660.6), favoring the comprehensive program and 82% of participants in the comprehensive group and 63% in the self-directed group achieved the MCID (adjusted relative risk, 1.3; 95% CI, 1.0-1.7; P=.03). Both primary treatment effects persisted at 12 months favoring the comprehensive program. At 6 months, the ODI walk score and at 12 months the ZCQ, Medical Outcomes Study 36-Item Short-Form Health Survey-physical function and -bodily pain scores showed greater improvements favoring the comprehensive program. CONCLUSIONS A comprehensive conservative program demonstrated superior, large, and sustained improvements in walking ability and can be a safe nonsurgical treatment option for patients with neurogenic claudication due to LSS.
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Affiliation(s)
- Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology and UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Toronto, Ontario, Canada
| | - Danielle Southerst
- Occupational and Industrial Orthopaedic Centre, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY
| | - Michael Schneider
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Brian Budgell
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Claire Bombardier
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gillian Hawker
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Department of Orthopedics, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Yavin D, Casha S, Wiebe S, Feasby TE, Clark C, Isaacs A, Holroyd-Leduc J, Hurlbert RJ, Quan H, Nataraj A, Sutherland GR, Jette N. Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis. Neurosurgery 2018; 80:701-715. [PMID: 28327997 DOI: 10.1093/neuros/nyw162] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 01/01/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure. OBJECTIVE To summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications. METHODS A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models. RESULTS The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality. CONCLUSION Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).
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Affiliation(s)
- Daniel Yavin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Steven Casha
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Samuel Wiebe
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.,Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Thomas E Feasby
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.,Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Callie Clark
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Albert Isaacs
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.,Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - R John Hurlbert
- Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Andrew Nataraj
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Garnette R Sutherland
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Nathalie Jette
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Canada.,Division of Neurology, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Canada.,The O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Calgary, Canada
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Objective measurement of function following lumbar spinal stenosis decompression reveals improved functional capacity with stagnant real-life physical activity. Spine J 2018; 18:15-21. [PMID: 28962914 PMCID: PMC5732871 DOI: 10.1016/j.spinee.2017.08.262] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/31/2017] [Accepted: 08/28/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) is a prevalent and costly condition associated with significant dysfunction. Alleviation of pain and improvement of function are the primary goals of surgical intervention. Although prior studies have measured subjective improvements in function after surgery, few have examined objective markers of functional improvement. PURPOSE We aimed to objectively measure and quantify changes in physical capacity and physical performance following surgical decompression of LSS. STUDY DESIGN/SETTING Prospective cohort study. PATIENT SAMPLE Thirty-eight patients with LSS determined by the treating surgeon's clinical and imaging evaluation, and who were scheduled for surgical treatment, were consecutively recruited at two academic medical facilities, with 28 providing valid data for analysis at baseline and 6 months after surgery. OUTCOME MEASURES Before surgery and at 6 months after surgery, participants provided 7 days of real-life physical activity (performance) using ActiGraph accelerometers; completed two objective functional capacity measures, the Short Physical Performance Battery and Self-Paced Walking Test; and completed three subjective functional outcome questionnaires, Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36. METHODS Physical activity, as measured by continuous activity monitoring, was analyzed as previously described according to the 2008 American Physical Activity Guidelines. Paired t tests were performed to assess for postsurgical changes in all questionnaire outcomes and all objective functional capacity measures. Chi-square analysis was used to categorically assess whether patients were more likely to meet these physical activity recommendations after surgery. RESULTS Participants were 70.1 years old (±8.9) with 17 females (60.7%) and an average body mass index of 28.4 (±6.2). All subjective measures (Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36) improved significantly at 6 months after surgery, as did objective functional measures of capacity including balance, gait speed, and ambulation distance (Short Physical Performance Battery, Self-Paced Walking Test). However, objectively measured performance (real-life physical activity) did not change following surgery. Although fewer participants qualified as inactive (54% vs. 71%), and more (11% vs. 4%) met the physical activity guideline recommendations at the 6-month follow-up, these differences were not statistically significant (p=.22) CONCLUSIONS: This is the first study, of which we are aware, to objectively evaluate changes in postsurgical performance (real-life physical activity) in people with LSS. We found that at 6 months after surgery for LSS, participants demonstrated significant improvements in self-reported function and objectively measured physical capacity, but not physical performance as measured by continuous activity monitoring. This lack of improvement in performance, despite improvements in self-reported function and objective capacity, suggests a role for postoperative rehabilitation focused specifically on increasing performance after surgery in the LSS population.
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Concurrent Validity and Responsiveness of PROMIS Health Domains Among Patients Presenting for Anterior Cervical Spine Surgery. Spine (Phila Pa 1976) 2017; 42:E1357-E1365. [PMID: 28742757 DOI: 10.1097/brs.0000000000002347] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim of this study was to determine the validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains. SUMMARY OF BACKGROUND DATA PROMIS health domains (anxiety, depression, fatigue, pain, physical function, satisfaction with participation in social roles, sleep disturbance) may measure quality of care and determine minimal important differences (MIDs) after spine surgery. We examined concurrent validity of PROMIS domains before and PROMIS domain MIDs after anterior cervical spine surgery. METHODS We included 148 adults undergoing cervical spine surgery from February 2015 through June 2016. We determined concurrent validity by correlations of preoperative PROMIS domains with legacy measures and responsiveness of PROMIS domains using distribution-based and anchor-based criteria (preoperative to postoperative change, within 6 months) anchored to treatment expectations (assessed using North American Spine Society Patient Satisfaction Index criteria). Statistical significance was accepted as P < 0.05. RESULTS All PROMIS domains showed moderate to strong correlations with Neck Disability Index, Short-Form Health Survey, version 2 (SF-12v2), and Brief Pain Inventory pain interference and weak correlations with intensity of arm/neck pain (except between PROMIS pain and neck pain [r = 0.45, P < 0.001] and PROMIS physical function and SF-12v2 physical [r = -0.14, P = 0.138] and mental [r = 0.39, P < 0.001] components). PROMIS domains were well correlated with Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8 except PROMIS physical function (r = -0.29, P = 0.002). Distribution-based PROMIS MID estimates ranged from 2.3 to 3.9 points. Incorporating cross-sectional and longitudinal anchor-based criteria, final PROMIS MID estimates were as follows: anxiety, -5.7; depression, -4.6, fatigue, -5.8; pain, -5.2; physical function, 4.5; satisfaction with participation in social roles, 4.4; and sleep disturbance, -7.4. CONCLUSION PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life. LEVEL OF EVIDENCE 2.
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The Timing of Surgery Affects Return to Work Rates in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting. Clin Spine Surg 2017; 30:E1444-E1449. [PMID: 28857967 DOI: 10.1097/bsd.0000000000000573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE The objective of this study is to determine how time to surgery affects outcomes for degenerative lumbar stenosis (DLS) in a workers' compensation (WC) setting. SUMMARY OF BACKGROUND DATA WC subjects are known to be a clinically distinct population with variable outcomes following lumbar surgery. No study has examined the effect of time to surgery in this clinically distinct population. MATERIALS AND METHODS A total of 227 Ohio WC subjects were identified who underwent primary decompression for DLS between 1993 and 2013. We allocated patients into 2 groups: those that received operative decompression before and after 1 year of symptom onset. Our primary outcome was, if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for >6 months. RESULTS The early cohort had a significantly higher RTW rate [50% (25/50) vs. 30% (53/117); P=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that time to surgery remained a significant negative predictor of RTW status (P=0.04; odds ratio, 0.48; 95% confidence interval, 0.23-0.91). Patients within the early surgery cohort cost on average, $37,332 less in total medical costs than those who opted for surgery after 1 year (P=0.01). Furthermore, total medical costs accrued over 3 years after index surgery was on average, $13,299 less when patients received their operation within 1 year after symptom onset (P=0.01). CONCLUSIONS Overall, time to surgery had a significant impact on clinical outcomes in WC subjects receiving lumbar decompression for DLS. Patients who received their operation within 1 year had a higher RTW rate, lower medical costs, and lower costs accrued over 3 years after index surgery. The results presented can perhaps be used to guide surgical decision-making and provide predictive value for the WC population.
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Lumbar Spinous Process Fixation and Fusion: A Systematic Review and Critical Analysis of an Emerging Spinal Technology. Clin Spine Surg 2017; 30:E1279-E1288. [PMID: 27438402 DOI: 10.1097/bsd.0000000000000411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY DESIGN A systematic review. OBJECTIVE The available literature on interspinous rigid fixation/fusion devices (IFD) was systematically reviewed to explore the devices' efficacy and complication profile. SUMMARY OF BACKGROUND DATA The clinical application of new spinal technologies may proceed without well-established evidence, as is the case with IFDs. IFDs are plate-like devices that are attached to the lateral aspects of 2 adjacent spinous processes to promote rigidity at that segment. Despite almost a decade since the devices' introduction, the literature regarding efficacy and safety is sparse. Complications have been reported but no definitive study is known to the authors. METHODS A systematic review of the past 10 years of English literature was conducted according to PRISMA guidelines. The timeframe was chosen based on publication of the first study containing a modern IFD, the SPIRE, in 2006. All PubMed publications containing MeSH headings or with title or abstract containing any combination of the words "interspinous," "spinous process," "fusion," "fixation," "plate," or "plating" were included. Exclusion criteria consisted of dynamic stabilization devices (X-Stop, DIAM, etc.), cervical spine, pediatrics, and animal models. The articles were blinded to author and journal, assigned a level of evidence by Oxford Centre of Evidence-Based Medicine (OCEBM) criteria, and summarized in an evidentiary table. RESULTS A total of 293 articles were found in the initial search, of which 15 remained after examination for exclusion criteria. No class I or class II evidence regarding IFDs was found. IFDs have been shown by methodologically flawed and highly biased class III evidence to reduce instability at 1 year, without statistical comparison of complication rates against other treatment modalities. CONCLUSIONS Although IFDs are heavily marketed and commonly applied in modern practice, data on safety and efficacy are inadequate. The paucity of evidence warrants reexamination of these devices' value and indications by the spine surgery community.
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Ramakrishnan A, Webb KM, Cowperthwaite MC. One-year outcomes of early-crossover patients in a cohort receiving nonoperative care for lumbar disc herniation. J Neurosurg Spine 2017; 27:391-396. [DOI: 10.3171/2017.2.spine16760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors comprehensively studied the recovery course and 1-year outcomes of early-crossover patients who were randomized to the nonoperative care arm of the Leiden–The Hague Spine Intervention Prognostic Study. The primary goal was to gain insight into the differences in the recovery patterns of early-crossover patients and those treated nonoperatively; secondary goals were to identify predictors of good 1-year outcomes, and to understand when and why patients were likely to cross over.METHODSIndividual EuroQol-5D scores were obtained at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks for 142 patients. Early-crossover patients were defined as those electing to undergo surgery during the first 12 weeks of treatment. Crossover and noncrossover groups were compared using Kruskal-Wallis, Wilcoxon-Mann-Whitney, and chi-square tests. Linear mixed-effects models were used to examine the growth trajectories of crossover and noncrossover groups. Recursive partitioning trees were used to model crossover events and the timing of crossover decisions. Multivariable logistic regression models were used to identify predictors of good 1-year outcomes.RESULTSOf the 142 patients randomized to receive prolonged nonoperative care, 136 were selected for the study. In this cohort, 43/136 (32%) opted for surgery, and 31/43 (72%) of crossover events occurred before the 12-week time point. Early-crossover patients had significantly greater functional impairment at Week 2 than noncrossover patients (p = 0.031), but experienced greater recovery by 26 weeks and better 1-year outcomes (p = 0.045). Patients who did not experience an improvement in their symptoms between 2 and 8 weeks were more likely to cross over (OR 3.5, 95% CI 1.2–10.1; p = 0.01). Recursive partitioning trees were able to identify crossover patients with 76% accuracy. Regression models suggested that better recovery at 26 weeks (p < 0.01) was predictive of good 1-year outcome; declining health status between Weeks 4 and 8 was negatively predictive of good outcome (p < 0.01).CONCLUSIONSThis study is the first to comprehensively analyze the recovery and outcomes of crossover patients, and compare them to nonoperatively treated patients. The results suggest that patients who have a low EuroQol-5D score during the early weeks of treatment and who do not respond to nonoperative care during the first few weeks of treatment are most likely to cross over. Early-crossover patients experience a greater rate of recovery and more frequently have a good 1-year outcome when compared with nonoperatively treated patients. The current results motivate a broader investigation into the timing of surgery and the identification of patient populations that will be most benefited by early surgical treatment for lumbar disc herniation.
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Affiliation(s)
| | | | - Matthew C. Cowperthwaite
- 1NeuroTexas Institute Research Foundation, Austin; and
- 2Center for Systems and Synthetic Biology, The University of Texas at Austin, Texas
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Nonsurgical Treatment Choices by Individuals with Lumbar Intervertebral Disc Herniation in the United States: Associations with Long-term Outcomes. Am J Phys Med Rehabil 2017; 96:557-564. [PMID: 28045705 DOI: 10.1097/phm.0000000000000685] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The objectives of this study were to (1) evaluate differences between patients with lumbar intervertebral disc herniation who received physical therapy (PT) and those who did not; (2) identify factors associated with receiving PT; and (3) examine the influence of PT on clinical outcomes over the course of 1 yr. DESIGN An observational cohort study using data from the Spine Patient Outcomes Research Trial was conducted. This study included 363 patients with intervertebral disc herniation who received nonsurgical management within 6 wks of enrollment. Baseline characteristics were compared between patients who received PT and those who did not. Multivariate logistic regression examined factors predictive of patients receiving PT. Mixed effects models were used to compare primary outcomes (Short-Form Survey 36 bodily pain and physical function and modified Oswestry Index) at 3 and 6 mos and 1 yr after enrollment. RESULTS Forty percent of the nonsurgical cohort received PT. Higher disability scores, neurological deficit, and patient preference predicted PT use. Compared with other nonsurgical management strategies, standard care PT was not associated with a significant difference in pain, disability, or surgery over 1 yr. CONCLUSIONS Many patients with intervertebral disc herniation seek secondary care for persisting symptoms and pursue nonsurgical management. The best management strategy is unclear and further research is needed to examine appropriate sequencing and selection of treatment.
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Lee SI, Campion A, Huang A, Park E, Garst JH, Jahanforouz N, Espinal M, Siero T, Pollack S, Afridi M, Daneshvar M, Ghias S, Sarrafzadeh M, Lu DC. Identifying predictors for postoperative clinical outcome in lumbar spinal stenosis patients using smart-shoe technology. J Neuroeng Rehabil 2017; 14:77. [PMID: 28720144 PMCID: PMC5516369 DOI: 10.1186/s12984-017-0288-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 07/06/2017] [Indexed: 11/21/2022] Open
Abstract
Background Approximately 33% of the patients with lumbar spinal stenosis (LSS) who undergo surgery are not satisfied with their postoperative clinical outcomes. Therefore, identifying predictors for postoperative outcome and groups of patients who will benefit from the surgical intervention is of significant clinical benefit. However, many of the studied predictors to date suffer from subjective recall bias, lack fine digital measures, and yield poor correlation to outcomes. Methods This study utilized smart-shoes to capture gait parameters extracted preoperatively during a 10 m self-paced walking test, which was hypothesized to provide objective, digital measurements regarding the level of gait impairment caused by LSS symptoms, with the goal of predicting postoperative outcomes in a cohort of LSS patients who received lumbar decompression and/or fusion surgery. The Oswestry Disability Index (ODI) and predominant pain level measured via the Visual Analogue Scale (VAS) were used as the postoperative clinical outcome variables. Results The gait parameters extracted from the smart-shoes made statistically significant predictions of the postoperative improvement in ODI (RMSE =0.13, r=0.93, and p<3.92×10−7) and predominant pain level (RMSE =0.19, r=0.83, and p<1.28×10−4). Additionally, the gait parameters produced greater prediction accuracy compared to the clinical variables that had been previously investigated. Conclusions The reported results herein support the hypothesis that the measurement of gait characteristics by our smart-shoe system can provide accurate predictions of the surgical outcomes, assisting clinicians in identifying which LSS patient population can benefit from the surgical intervention and optimize treatment strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12984-017-0288-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sunghoon I Lee
- College of Information and Computer Science, UMass Amherst, Amherst, USA
| | - Andrew Campion
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Alex Huang
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Eunjeong Park
- Cardiovascular Research Institute, Yonsei University College of Medicine, Los Angeles, USA
| | - Jordan H Garst
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Nima Jahanforouz
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Marie Espinal
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Tiffany Siero
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Sophie Pollack
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Marwa Afridi
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Meelod Daneshvar
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | - Saif Ghias
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA.,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA.,Department of Neurosurgery, UCLA, Los Angeles, USA
| | | | - Daniel C Lu
- Neuroplasticity and Repair Laboratory, UCLA, Los Angeles, USA. .,Neuromotor Recovery and Rehabilitation Center, UCLA, Los Angeles, USA. .,Department of Neurosurgery, UCLA, Los Angeles, USA. .,Department of Orthopaedic Surgery, UCLA, Los Angeles, USA.
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Lau YYO, Lee RKL, Griffith JF, Chan CLY, Law SW, Kwok KO. Changes in dural sac caliber with standing MRI improve correlation with symptoms of lumbar spinal stenosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2666-2675. [DOI: 10.1007/s00586-017-5211-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 07/03/2017] [Indexed: 12/15/2022]
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Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers' Compensation Setting. Spine (Phila Pa 1976) 2017; 42:1017-1023. [PMID: 27831969 DOI: 10.1097/brs.0000000000001970] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to compare outcomes in Workers' compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability. SUMMARY OF BACKGROUND DATA The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone. METHODS Three hundred sixty-four Ohio WC subjects were identified who underwent primary decompression (DC) or primary decompression and fusion (DC + F) for DLS alone between 1993 and 2013. Our primary outcome was if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for more than 6 months. A number of secondary outcomes were collected and analyzed. RESULTS The DC cohort had a significantly higher RTW rate [36% (83/227) vs. 25% (54/212); P = 0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that fusion with operative decompression remained a significant negative predictor of RTW status (P = 0.04; odds ratio: 0.58, 95% confidence interval: 0.34-0.99). Within the DC cohort, the rate of postoperative instability and subsequent fusion was 8%. Furthermore, subjects who received an adjunctive fusion cost of the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone. CONCLUSION Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population. LEVEL OF EVIDENCE 3.
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Abstract
STUDY DESIGN Prospective noninterventional observation. OBJECTIVE To examine factors that influence a patient's real decision to accept the offer of surgery for lumbar spinal stenosis in a relatively controlled situation. SUMMARY OF BACKGROUND DATA A patient's decision to undergo spine surgery might be influenced by factors other than pathology. However, there is limited research exploring the decision. METHODS A study performed for other purposes recruited persons aged 55-90 years with medical record evidence of an offer of surgery for spinal stenosis by a university faculty surgeon. Inclusion criteria included neurogenic claudication, subjectively positive imaging, and difficulty walking 200 yards. Potential subjects with additional disabling conditions (eg, lower limb amputation), conditions that might mimic stenosis (eg, polyneuropathy), or some contraindications to invasive treatment (eg, anticoagulation) were excluded. Subjects filled out questionnaires on function, quality of life, pain, and health, and were examined by a spine surgeon masked to diagnostic category (Other recruits had back pain or no symptoms). Telephone follow-up 6-12 months later determined whether surgery was done. RESULTS Of 39 qualifying subjects, 20 followed through with surgery. A binary logistic regression revealed that significant factors that influence patient decision making included SF-36 measures of "Comparative Health" and "Role Limit Emotional" as well as the subject's overall perception of their quality of life. The combination of all 3 factors yielded a predictive model (P=0.031). Individually, however, only "Comparative Health" was significant and able to predict a decision to proceed with surgery (P=0.036). CONCLUSIONS In this population with significant disability, uncomplicated medical history, and a relatively clear diagnosis, the decision to accept surgical intervention was influenced by issues of perceived overall health and quality of life. Interventions to change real or perceived overall health may impact patient acceptance of surgery.
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Lam WWK, Loke AY. Factors and concerns of patients that influence the decision for spinal surgery and implications for practice: A review of literature. Int J Orthop Trauma Nurs 2016; 25:11-18. [PMID: 28314703 DOI: 10.1016/j.ijotn.2016.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/26/2016] [Accepted: 09/05/2016] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN A literature review. OBJECTIVES To identify the factors and concerns that influence the decision of patients to undergo spinal surgery. METHODS Electronic databases MEDLINE, PsycINFO, CINAHL plus, and Embase were searched for relevant studies published from 2000 to 2015. The keywords for the search included: spine surgery OR spinal stenosis AND decision making OR consideration OR preference OR willingness OR concern. Seven quantitative studies met the criteria for inclusion and were included in this review. RESULTS The findings showed that patients were more likely to decide on surgery when they were suffering from severe bodily pain, poor physical function, poor psychosocial health and a higher level of functional disability. Concerns that affected the patients' decision on whether or not to opt for surgery were: the benefits weighed against the perceived risks of different modalities of treatment, the effectiveness of medical treatments, their level of satisfaction with their symptoms and a preference for autonomy or a reliance on the opinion of medical professionals. The findings relating to patient characteristics and preference for surgery were inconsistent. CONCLUSION Patients go through a complex and a multi-factorial process in making the decision whether or not to undergo surgery, which calls for decision support interventions that will help them to make the decision.
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Affiliation(s)
| | - Alice Yuen Loke
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
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Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review. Arch Phys Med Rehabil 2016; 98:165-172. [PMID: 27576191 DOI: 10.1016/j.apmr.2016.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/30/2016] [Accepted: 07/27/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults. DATA SOURCES A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations. STUDY SELECTION Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers. DATA EXTRACTION Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined. DATA SYNTHESIS A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy. CONCLUSIONS This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.
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