Life expectancy after lumbar spine surgery: one- to eleven-year follow-up of 1015 patients

Assessing Morbidity and Outcomes of Posterior Lumbar Fusion in Elderly Patients: A Systematic Review and Meta-Analysis

This review aims to evaluate the morbidity, mortality, and functional outcomes associated with instrumented posterior lumbar arthrodesis in elderly patients aged 65 years and above. A systematic review and meta-analysis adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted using PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane, Embase, Emcare, CINAHL (Cumulated Index to Nursing and Allied Health Literature), and the international prospective register of systematic reviews (PROSPERO) databases. Relevant studies were identified based on inclusion criteria, with data extraction focusing on mortality rates, operative duration, blood loss, length of hospital stay, complication rates, and clinical and functional outcomes. Functional assessments included the Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the Visual Analogue Scale (VAS) for pain intensity. Out of 6,241 studies, 45 met the inclusion criteria. The pooled mortality rate was 0.7% (95%CI: 0.2-1.3%), with a mean operative duration of 181.6 minutes (95%CI: 138.8-224.5 minutes) and an average blood loss of 337.8 ml. Complication rates included dural tears (4.3%), neurological deficits (2.2%), metalwork failure (7.06%), and wound dehiscence (3.29%). Significant postoperative functional improvements were observed, with reductions in ODI by 3.47 points, leg pain intensity by 4.29 points on the VAS, back pain intensity by 4.95 points on the VAS, and an increase in JOA scores by 9.9 points. Despite concerns regarding morbidity and mortality, this meta-analysis highlights that instrumented posterior lumbar arthrodesis in elderly patients is associated with considerable improvements in clinical and functional outcomes, supporting its role in the management of degenerative spinal conditions in this population.

Mortality in patients older than 65 years undergoing surgery for degenerative lumbar spine disease: a comparison with the general population

BACKGROUND

The increased life expectancy and prevalence of spondylarthrosis have led to a growing frequency of spinal surgery in older people. This study aims to assess whether there is an excess mortality concerning that expected in the general population associated with surgical procedures performed in patients over 65 years old for a degenerative disease of the lumbar spine.

METHODS

All patients aged 65 years or older undergoing surgery at a single center between 2009 and 2019 for lumbar spine degenerative disease were included. Standardized mortality ratios (SMRs) were estimated to compare the mortality risk with the expected in the Spanish population for the same age, gender, and calendar-period. Multivariable Cox analysis was employed to determine risk factors of mortality.

RESULTS

A total of 411 procedures were analyzed. The mean age was 72.6 years old. SMR was 0.67 (CI 95% 0.54-0.84). That benefit was significant in women after gender stratification. Patients operated on between 65-84 years old had a lower mortality rate than that expected for the general population. For patients aged 85 or older, the observed mortality was not different from that expected in the general population. Multivariable Cox analysis observed an association between higher mortality and the variables age, male, and Charlson comorbidity index score.

CONCLUSIONS

Compared with the general population, patients over 65 years old who underwent spinal surgery for degenerative disease of the lumbar spine experienced a reduction in mortality. This effect was particularly significant in women and patients aged 65-84 years. Age, male gender, and Charlson comorbidity index score were associated with higher mortality risk.

Spine Surgery in a Geriatric Population. Is it Really Different?

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.

Surgical Treatment of Single-Level Lumbar Stenosis Is Associated with Lower 2-Year Mortality and Total Cost Compared with Nonsurgical Treatment: A Risk-Adjusted, Paired Analysis

BACKGROUND

Spine surgery has demonstrated cost-effectiveness in reducing pain and restoring function, but the impact of spine surgery relative to nonsurgical care on longer-term outcomes has been less well described. Our objective was to compare single-level surgical treatment for lumbar stenosis, with or without spondylolisthesis, and nonsurgical treatment with respect to patient mortality, resource utilization, and health-care payments over the first 2 years following initial treatment.

METHODS

A retrospective review of the Medicare National Database Fee for Service Files from 2011 to 2017 was performed. A 2-year prediction of mortality risk (risk stratification index, RSI) was used as a measure of patient baseline health. Patients (88%) were matched by RSI and demographics. Mortality, spine-related health-care utilization, and 2-year total Medicare payments for patients undergoing surgical treatment were compared with matched patients undergoing nonsurgical treatment.

RESULTS

We identified 61,534 patients with stenosis alone and 83,813 with stenosis and spondylolisthesis. Surgical treatment was associated with 28% lower 2-year mortality compared with matched patients undergoing nonsurgical treatment. Total Medicare payments were significantly lower for patients with stenosis alone undergoing laminectomy alone and for patients with stenosis and spondylolisthesis undergoing laminectomy with or without fusion compared with patients undergoing nonsurgical treatment. There was no significant difference in mortality when fusion or laminectomy was compared with combined fusion and laminectomy. However, laminectomy alone was associated with significantly lower 2-year payments when treating stenosis with or without spondylolisthesis.

CONCLUSIONS

Surgical treatment for stenosis with or without spondylolisthesis within the Medicare population was associated with significantly lower mortality and total medical payments at 2 years compared with nonsurgical treatment, although residual confounding could have contributed to these findings.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The influence of comorbidities on the treatment outcome in symptomatic lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) affects mainly elderly patients. To this day, it is unclear whether comorbidities influence treatment success. The aim of this systematic review and meta-analysis was to assess the impact of comorbidities on the treatment effectiveness in symptomatic LSS.

METHODS

We conducted a systematic review and meta-analysis and reviewed prospective or retrospective studies from Medline, Embase, Cochrane Library and CINAHL from inception to May 2020, including adult patients with LSS undergoing surgical or conservative treatment. Main outcomes were satisfaction, functional and symptoms improvement, and adverse events (AE). Proportions of outcomes within two subgroups of a comorbidity were compared with risk ratio (RR) as summary measure. Availability of ≥3 studies for the same subgroup and outcome was required for meta-analysis.

RESULTS

Of 72 publications, 51 studies, mostly assessing surgery, there was no evidence reported that patients with comorbidities were less satisfied compared to patients without comorbidities (RR 1.06, 95% confidence interval (CI) 0.77 to 1.45, I 2 94%), but they had an increased risk for AE (RR 1.46, 95% CI 1.06 to 2.01, I 2 72%). A limited number of studies found no influence of comorbidities on functional and symptoms improvement. Older age did not affect satisfaction, symptoms and functional improvement, and AE (age >80 years RR 1.22, 95% CI 0.98 to 1.52, I 2 60%). Diabetes was associated with more AE (RR 1.72, 95% CI 1.19 to 2.47, I 2 58%).

CONCLUSION

In patients with LSS and comorbidities (in particular diabetes), a higher risk for AE should be considered in the treatment decision. Older age alone was not associated with an increased risk for AE, less functional and symptoms improvement, and less treatment satisfaction.

Influence of Frailty on Life Expectancy in Octogenarians After Lumbar Spine Surgery

Objective

Many studies have reported positive surgical outcomes and decreased mortality after spine surgery in the elderly population, including patients between 85 and 90 years of age. Here, in addition to patient age, we investigated the influence of frailty on short and long-term mortality in octogenarians after lumbar surgery.

Methods

We performed a retrospective analysis of 162 patients over 80 years of age who underwent posterior lumbar fusion or decompressive laminectomy between January 2011 and September 2016. We examined patient survival and modified frailty index (mFI) from medical records.

Results

By October 2019, 29 of 162 patients had expired (follow-up period: 1–105 months). Three-month mortality was 1.9%, and 1-year mortality was 4.9%. Frailty did not affect long-term survival at 1 year but was associated with 3-month mortality (p = 0.024).

Conclusion

There was no relationship in long-term survival according to frailty in patients 80 years of age or older, but a difference was identified in short-term mortality. When making a surgical decision for lumbar spine surgery in frail patients over 80 years of age, surgeons should pay attention to the short-term prognosis.

Impact of Sarcopenia on Clinical Outcomes of Minimally Invasive Lumbar Decompression Surgery

The purpose of this study was to clarify the clinical impact of sarcopenia on the outcome of minimally invasive lumbar decompression surgery. The records of 130 patients who were >65 years and underwent minimally invasive lumbar decompression surgery were retrospectively reviewed. We collected the Japanese Orthopaedic Association (JOA) score before surgery and at the final follow-up and measured appendicular muscle mass using bioimpedance analysis, hand-grip strength and gait speed. We diagnosed the patients with sarcopenia, dynapenia and normal stages using the European Working Group on Sarcopenia in Older People definition and used cutoff thresholds according to the algorithm set by the Asian Working Group for Sarcopenia. The average age of patients undergoing surgery was 76.9 years old. The JOA score improved from 12.6 points preoperatively to 24.3 points at final follow up. The prevalence of the sarcopenia, dynapenia and normal stages was 20.0, 31.6 and 43.8%. Clinical outcomes, such as JOA score, JOA score improvement ratio, visual analog scale for low back pain, leg pain and numbness, were not significantly different among each group. Multiple regression analysis showed that preoperative JOA score and low physical performance (low gait speed) were independently associated with poor clinical outcomes. The JOA score improved after minimally invasive lumbar decompression surgery even when the patients were diagnosed as being at different stages of sarcopenia. Low physical performance had the greater clinical impact on the clinical outcome of lumbar surgery than low skeletal muscle index.

Relationship of Success Rate for Balloon Adhesiolysis with Clinical Outcomes in Chronic Intractable Lumbar Radicular Pain: A Multicenter Prospective Study

Combined balloon decompression and epidural adhesiolysis has been reported to be effective in refractory lumbar spinal stenosis. Many cases of intractable stenosis have symptom-related multiple target sites for interventional treatment. In this situation it may not be possible to perform balloon adhesiolysis, or even only epidural adhesiolysis, for all target sites. Therefore, this multicenter prospective observational study aimed to evaluate the relationship of successful ballooning rate for multiple target sites with clinical outcome. Based on the ballooning success rate of multiple target sites, the patients were divided into three groups: below 50%, 50-85%, and above 85% ballooning. A greater ballooning success rate for multiple target sites provided a more decreased pain intensity and improved functional status in patients with chronic refractory lumbar spinal stenosis, and the improvement was maintained for 6 months. The estimated proportions of successful responders according to a multidimensional approach in the below 50%, 50-85%, and above 85% balloon success groups at 6 months after the procedure were 0.292, 0.468, and 0.507, respectively (p = 0.038). Our study suggests the more successful balloon adhesiolysis procedures for multiple target lesions are performed, the better clinical outcome can be expected at least 6 months after treatment.

Surgical treatment improves survival of elderly with axis fracture-a national population-based multiregistry cohort study

BACKGROUND CONTEXT

Fractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically.

PURPOSE

We aimed to analyze whether surgery improves survival of elderly with C2 fractures.

STUDY DESIGN/SETTING

An observational population-based longitudinal multi-registry study was carried out.

PATIENT SAMPLE

Swedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample.

OUTCOME MEASURES

Survival after C2 fracture according to non-surgical and surgical treatment was the outcome measure.

METHODS

We included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index.

RESULTS

Of the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79-0.97). Among those above 88 years of age (95% confidence interval: 85-92), surgical treatment lost its effect on survival.

CONCLUSIONS

Despite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.

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

OBJECTIVE

Examining spine surgery patterns over time is crucial to provide insights into variations and changes in clinical decision making. Changes in the number of surgeries, surgical methods, reoperation rates, and cost-effectiveness were analyzed for all patients who underwent surgery for lumbar spinal stenosis without spondylolisthesis in 2003 (2003 cohort) and 2008 (2008 cohort).

METHODS

The national health insurance database was used to create the 2003 cohort (n = 10,990) and 2008 cohort (n = 27,942). The surgical methods were classified into decompression and fusion surgery. The cumulative reoperation probability between those surgeries was calculated using the Kaplan-Meier method in the 2003 cohort and 2008 cohort. Comparison of the incremental cost-effectiveness ratios showed the additional direct cost of a 1% change in the reoperation probability.

RESULTS

The surgical volume increased 2.54-fold in the 2008 cohort. The age-adjusted number of surgeries per 1 million people increased 2.6-fold (from 154 in the 2003 cohort to 399 in the 2008 cohort) in aged patients and 1.9-fold (from 154 in the 2003 cohort to 291 in the 2008 cohort) in patients 20-59 years old in the 2008 cohort. The proportion of fusion surgeries increased from 20.3% in the 2003 cohort to 37.0% in the 2008 cohort. In total, the 5-year reoperation probabilities increased from 8.1% in the 2003 cohort to 11.2% in the 2008 cohort. Fusion decreased the reoperation probability by 1% at the cost of 1,711 U.S. dollars.

CONCLUSIONS

The increased numbers of spinal surgeries, fusion surgeries, and surgeries in older patients in a recent cohort were noteworthy. However, the increased surgical volume and fusion surgeries did not reduce the reoperation rate.

Effects of multilevel posterior ligament dissection after spinal instrumentation on adjacent segment biomechanics as a potential risk factor for proximal junctional kyphosis: a biomechanical study

Background

Spinous processes and posterior ligaments, such as inter- and supraspinous ligaments are often sacrificed either deliberately to harvest osseous material for final spondylodesis e.g. in deformity corrective surgery or accidentally after posterior spinal instrumentation. This biomechanical study evaluates the potential destabilizing effect of a progressive dissection of the posterior ligaments (PL) after instrumented spinal fusion as a potential risk factor for proximal junctional kyphosis (PJK).

Methods

Twelve calf lumbar spines were instrumented from L3 to L6 (L3 = upper instrumented vertebra, UIV) and randomly assigned to one of the two study groups (dissection vs. control group). The specimens in the dissection group underwent progressive PL dissection, followed by cyclic flexion motion (250 cycles, moment: + 2.5 to + 20.0 Nm) to simulate physical activity and range of motion (ROM) testing of each segment with pure moments of ±15.0 Nm after each dissection step. The segmental ROM in flexion and extension was measured. The control group underwent the same loading and ROM testing protocol, but without PL dissection.

Results

In the treatment group, the normalized mean ROM at L2-L3 (direct adjacent segment of interest, UIV/UIV + 1, PJK-level) increased to 104.7%, 107.3%, and 119.4% after dissection of the PL L4–L6, L3–L6, and L2–L6, respectively. In the control group the mean ROM increased only to 103.2%, 106.7%, and 108.7%. The ROM difference at L2-L3 with regard to the last dissection of the PL was statistically significant (P = 0.017) and a PL dissection in the instrumented segments showed a positive trend towards an increased ROM at UIV/UIV + 1.

Conclusions

A dissection of the PL at UIV/UIV + 1 leads to a significant increase in ROM at this level which can be considered to be a risk factor for PJK and should be definitely avoided during surgery. However, a dissection of the posterior ligaments within the instrumented segments while preserving the ligaments at UIV/UIV + 1 leads to a slight but not significant increase in ROM in the adjacent cranial segment UIV/UIV + 1 in the used experimental setup. Using this experimental setup we could not confirm our initial hypothesis that the posterior ligaments within a long posterior instrumentation should be preserved.

Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis

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).

Validation and Cross-cultural Adaptation of the Korean Version of the Zurich Claudication Questionnaire in Patients With Lumbar Spinal Stenosis

STUDY DESIGN

Linguistic and psychometric validation of a translated questionnaire.

OBJECTIVE

To validate the Korean version of Zurich claudication questionnaire (ZCQ) both linguistically and psychometrically.

SUMMARY OF BACKGROUND DATA

The ZCQ is considered as a disease specific and gold standard measure for evaluation of patients with lumbar spinal stenosis (LSS). However, there has been no validated Korean version of the ZCQ.

METHODS

The ZCQ was translated forward and backward, culturally adapted by 2 independent translators, and approved by an expert committee. The final version of the Korean ZCQ was added to a routine questionnaire including a visual analog pain scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the European Quality of Life-5 dimensions (EQ-5D). Psychometric validation included reliability by internal consistency using Cronbach's alpha, the test-retest reliability using intraclass correlation coefficient (ICC), and concurrent validity by comparing the Korean ZCQ to VAS for back/leg pain, ODI, and EQ-5D using Pearson correlation.

RESULTS

A total of 109 patients were included in this study. The test-retest intraclass correlation coefficient (ICC) of the ZCQ was shown to have good reliability for all three domains: the ICCs for symptom, function, and satisfaction domains were 0.79, 0.84, and 0.91, respectively. Internal consistency of the Korean ZCQ for the symptom, function, and satisfaction domains was also excellent (Cronbach α = 0.894, 0.939, and 0.961, respectively). For concurrent validity, all three domains of the Korean ZCQ were significantly correlated with external criteria including VAS for back/leg pain, ODI, and EQ-5D. In the assessment of responsiveness, 21 patients who completed the ZCQ both before and after surgery demonstrated significantly different scores for symptom and disability domains.

CONCLUSION

The validated Korean version of the ZCQ is a transculturally equivalent, reliable, and valid tool for use in assessing symptoms, function, and satisfaction with treatment in patients with LSS.

LEVEL OF EVIDENCE

3.

Is a gradual reduction of stiffness on top of posterior instrumentation possible with a suitable proximal implant? A biomechanical study

BACKGROUND CONTEXT

Proximal junctional kyphosis (PJK) is a challenging complication after rigid posterior instrumentation (RI) of the spine. Several risk factors have been described in literature so far, including the rigidity of the cranial aspect of the implant.

PURPOSE

The aim of this biomechanical study was to compare different proximal implants designed to gradually reduce the stiffness between the instrumented and non-instrumented spine.

STUDY DESIGN/SETTING

This is a biomechanical study.

METHODS

Eight calf lumbar spines (L2-L6) underwent RI with a titanium pedicle screw rod construct at L4-L6. The proximal transition segment (L3-L4) was instrumented stepwise with different supplementary implants-spinal bands (SB), cerclage wires (CW), hybrid rods (HR), hinged pedicle screws (HPS), or lamina hooks (LH)-and compared with an all-pedicle screw construct (APS). The flexibility of each segment (L2-L6) was tested with pure moments of ±10.0 Nm in the native state and for each implant at L3-L4, and the segmental range of motion (ROM) was evaluated.

RESULTS

On flexion and extension, the native uninstrumented L3-L4 segment showed a mean ROM of 7.3°. The CW reduced the mean ROM to 42.5%, SB to 41.1%, HR to 13.7%, HPS to 12.3%, LH to 6.8%, and APS to 12.3%. On lateral bending, the native segment L3-L4 showed a mean ROM of 15°. The CW reduced the mean ROM to 58.0%, SB to 78.0%, HR to 6.7%, HPS to 6.7%, LH to 10.0%, and APS to 3.3%. On axial rotation, the uninstrumented L3-L4 segment showed a mean ROM of 2.7°. The CW reduced the mean ROM to 55.6%, SB to 77.8%, HR to 55.6%, HPS to 55.6%, LH to 29.6%, and APS to 37.0%.

CONCLUSIONS

Using CW or SB at the proximal transition segment of a long RI reduced rigidity by about 60% in relation to flexion and extension in that segment, whereas the other implants tested had a high degree of rigidity comparable with APS. Clinical randomized controlled trials are needed to elucidate whether this strategy might be effective for preventing PJK.

Effectiveness and Factors Associated with Epidural Decompression and Adhesiolysis Using a Balloon-Inflatable Catheter in Chronic Lumbar Spinal Stenosis: 1-Year Follow-Up

OBJECTIVES

This study aimed to investigate the efficacy of the combined balloon decompression with a balloon-inflatable catheter (ZiNeu) in addition to conventional epidural adhesiolysis, and to identify factors that predict patient responses.

STUDY DESIGN

An institutional single-armed prospective observational study.

SUBJECTS

Chronic refractory lumbar spinal stenosis.

METHODS

This study was performed in 61 patients with spinal stenosis who suffered from chronic (at least 3 months) lumbar radicular pain with or without lower back pain. Patients had failed to maintain improvement for more than 1 month with conventional epidural injection. The numeric rating scale (NRS) and Oswestry disability index (ODI) were each measured at 1, 3, 6, and 12 months after percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter.

RESULTS

The percentage of successful responders was 72.1%, 60.7%, 57.4%, and 36.1% of patients at 1, 3, 6, and 12 months, respectively. A single combined treatment of percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter provided sufficient pain relief and functional improvement in patients with chronic refractory lumbar spinal stenosis, and the improvement was maintained for 12 months (P < 0.001). Multivariate logistic regression analysis showed that absence of diabetes independently predicted successful response at 12 months after percutaneous epidural decompression and adhesiolysis with the balloon catheter (Odds ratio = 0.080; 95% confidence interval = 0.009-0.676; P = 0.020).

CONCLUSIONS

The combined epidural adhesiolysis and balloon decompression with a ZiNeu catheter led to significant pain relief and functional improvement in a subset of patients with refractory spinal stenosis.

Lumbar Stenosis: A Recent Update by Review of Literature

Degeneration of the intervertebral disc results in initial relative instability, hypermobility, and hypertrophy of the facet joints, particularly at the superior articular process. This finally leads to a reduction of the spinal canal dimensions and compression of the neural elements, which can result in neurogenic intermittent claudication caused by venous congestion and arterial hypertension around nerve roots. Most patients with symptomatic lumbar stenosis had neurogenic intermittent claudication with the risk of a fall. However, although the physical findings and clinical symptoms in lumbar stenosis are not acute, the radiographic findings are comparatively severe. Magnetic resonance imaging is a noninvasive and good method for evaluation of lumbar stenosis. Though there are very few studies pertaining to the natural progression of lumbar spinal stenosis, symptoms of spinal stenosis usually respond favorably to non-operative management. In patients who fail to respond to non-operative management, surgical treatments such as decompression or decompression with spinal fusion are required. Restoration of a normal pelvic tilt after lumbar fusion correlates to a good clinical outcome.

Outcome and Complications in Surgical Treatment of Lumbar Stenosis or Spondylolisthesis in Geriatric Patients

Development of anesthesiology and improvement of surgical instruments enabled aggressive surgical treatment even in elderly patients, who require more active physical activities than they were in the past. However, there are controversies about the clinical outcome of spinal surgery in elderly patients with spinal stenosis or spondylolisthesis. The purpose of this study is to review the clinical outcome of spinal surgery in elderly patients with spinal stenosis or spondylolisthesis. MEDLINE search on English-language articles was performed. There were 39685 articles from 1967 to 2013 regarding spinal disease, among which 70 dealt with geriatric lumbar surgery. Eighteen out of 70 articles dealt with geriatric lumbar surgery under the diagnosis of spinal stenosis or spondylolisthesis. One was non-randomized prospective, and other seventeen reports were retrospective. One non-randomized prospective and twelve out of seventeen retrospective studies showed that old ages did not affect the clinical outcomes. One non-randomized prospective and ten of seventeen retrospective studies elucidated postoperative complications: some reports showed that postoperative complications increased in elderly patients, whereas the other reports showed that they did not increase. Nevertheless, most complications were minor. There were two retrospective studies regarding the mortality. Mortality which was unrelated to surgical procedure increased, but surgical procedure-related mortality did not increase. Surgery as a treatment option in the elderly patients with the spinal stenosis or spondylolisthesis may be reasonable. However, there is insufficient evidence to make strong recommendations regarding spinal surgery for geriatric patients with spinal stenosis and spondylolisthesis.

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

BACKGROUND CONTEXT

The evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.

PURPOSE

Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Sixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.

CONCLUSIONS

A clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Avaliação prospectiva da evolução funcional de pacientes tratados de estenose de canal lombar com descompressão sem artrodese

OBJETIVO: Avaliar se o procedimento cirúrgico com descompressão posterior sem artrodese da coluna lombar traz benefícios em avaliações prospectivas de dor e incapacidade. MÉTODOS: Dezesseis pacientes foram avaliados através de questionários de incapacidade e dor no período pré-operatório e durante o seguimento pós-operatório de um mês, seis meses e um ano, tendo sido realizada cirurgia de descompressão sem instrumentação pedicular ou artrodese. RESULTADOS: Foram observadas melhoras nos medidores de dor e incapacidade durante o seguimento de um ano pós-operatório em relação aos valores iniciais. CONCLUSÃO: A descompressão sem artrodese em pacientes com estenose de canal lombar demonstrou ser eficaz na melhora da dor e incapacidade em pacientes selecionados no seguimento de um ano pós-operatório.

Long-term health care utilisation and costs after spinal fusion in elderly patients

PURPOSE

Spinal fusion surgery rates in the elderly are increasing. Cost effectiveness analyses with relatively short-length follow-up have been performed. But the long-term effects in terms of health care use are largely unknown. The aim of the present study was to describe the long-term consequences of spinal fusion surgery in elderly patients on health care use and costs using a health care system perspective.

METHODS

194 patients undergoing spinal fusion between 2001 and 2005 (70 men, 124 women) with a mean age of 70 years (range 59-88) at surgery were included. Average length of follow-up was 6.2 years (range 0.3-9.0 years). Data on resource utilisation and costs were obtained from national registers providing complete coverage of all reimbursed contacts with primary- and secondary health care providers. Data were available from 3 years prior fusion surgery until the end of 2009.

RESULTS

Use of hospital-based health care increased in the year prior to and the first year following surgery. Hereafter it normalised to the level of the background population and was mainly composed of diseases unrelated to the spine. In contrast, the use of primary health care appeared to increase immediately after surgery and continued to increase to a level that significantly exceeded that of the background population. It could be demonstrated that the increase was mainly due to an increasing number of general practitioner consultations.

CONCLUSION

Spinal fusion surgery in older patients does not generate excess hospital-based health care use in the longer term as compared with the background population, but primary care use increases.

Low sense of coherence interferes with lumbar spinal stenosis patients' postoperative recovery: a prospective one-year follow-up study

In a prospective observational study (N = 97) we examined the changes in the SOC score after a surgical intervention for lumbar spinal stenosis (LSS) and the factors associated with low and high SOC scores. Logistic regression analyses were used to investigate the predictors for the lowest SOC tertile. The post-surgical recovery among the low SOC group halted on three-month follow-up, whereas in the high SOC group a steady improvement was detected up to one year postoperatively. Preoperative and postoperative depressive symptoms were highly pertinent to the SOC of LSS patients, both as an indicator and a predictor of a low one-year SOC.

Estudo prospectivo de avaliação de dor e incapacidade de pacientes operados de estenose de canal lombar com seguimento mínimo de dois anos

OBJETIVO: realizar uma análise prospectiva de dor e incapacidade em pacientes operados de estenose de canal lombar após dois anos do procedimento através da escala VAS e Roland Morris. MÉTODOS: trinta e oito pacientes foram avaliados por meio dos questionários em um momento pré-operatório, pós-operatório um mês, seis meses, um ano e dois anos, tendo sido realizada descompressão e artrodese com instrumentação pedicular associada. RESULTADOS: foi observado melhora nas análises comparativas de dor e incapacidade no decorrer do seguimento em relação aos valores iniciais, porém uma tendência à estabilização do quadro com sua evolução. CONCLUSÃO: o tratamento cirúrgico da estenose do canal lombar, quando criteriosamente indicado, melhora a dor e a incapacidade após dois anos de seguimento.

The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 1: functional outcome

STUDY DESIGN

Randomized, controlled, multi-center trial.

OBJECTIVE

To investigate the effect of direct current (DC) electrical stimulation on functional and clinical outcome after lumbar spinal fusion in patients older than 60 years.

SUMMARY OF BACKGROUND DATA

Older patients have increased complication rates after spinal fusion surgery. Treatments which have the possibility of enhancing functional outcome and fusion rates without lengthening the procedure could prove beneficial. DC-stimulation of spinal fusion has proven effective in increasing fusion rates in younger and "high risk" patients, but functional outcome measures have not been reported.

METHODS

A randomized, clinical trial comprising 5 orthopedic centers. The study included a total of 107 patients randomized to uninstrumented posterolateral lumbar spinal fusion with or without DC-stimulation. Functional outcome was assessed using Dallas Pain Questionnaire, SF-36, Low Back Pain Rating Scale pain index, and walking distance.

RESULTS

Follow-up after 1 year was 95/107 (89%). DC-stimulated patients had significant better outcome in 3 of 4 categories in the Dallas Pain Questionnaire, better SF-36 scores (not significantly), but no difference in pain scores were observed. Median walking distance at latest follow-up was better in the stimulated group (not significant). Walking distance was significantly associated with functional outcome. There was no difference in any of the functional outcome scores between patients who experienced a perioperative complication and those without complications.

CONCLUSION

The achievement of a good functional outcome was heavily dependent on the obtained walking distance. DC-stimulated patients tended to have better functional outcome as compared to controls. No negative effects of perioperative complications could be observed on the short-term functional outcome.

Restoration of bone turnover rate after decompression surgery in patients with symptomatic lumbar spinal stenosis: preliminary report

STUDY DESIGN

Prospective short-term longitudinal study.

OBJECTIVE

To investigate changes in the bone turnover rate in patients with lumbar spinal stenosis (LSS) before and after decompression surgery. SUMMARY OF BACK GROUND DATA: Decompression surgery enables elderly patients with LSS to participate in daily activities and physical exercise by reducing or alleviating leg and back pain. However, there have been no studies to date regarding the effect of decompression surgery on bone metabolism in such patients.

METHODS

Twenty-three patients with spinal stenosis who were scheduled to undergo decompression surgery were enrolled in our study. Ten patients were given oral bisphosphonates after the operation (B+ group), while the remaining 13 patients did not receive oral bisphosphonate (B- group). In both groups, walking distance without rest, the Oswestry Disability Index (ODI) scores, duration of symptoms, bone formation, and resorption markers, and bone mineral density were recorded before surgery. Three months after surgery, bone turnover markers, a single trial for walking distance without rest and ODI scores were measured for both groups.

RESULTS

Three months after the operation, the bone resorption marker u-NTx was decreased significantly for both groups. Although there was a decrease in bALP, a bone formation maker, in both groups, the change in each group was not statistical significant. Distance in a single trial walk was increased and ODI scores were decreased significantly for both groups.

CONCLUSION

This study suggests that decompression surgery has a beneficial effect on bone metabolism in patients with LSS who have walking intolerance and limited physical activity.