Spine patient outcomes research trial: do outcomes vary across centers for surgery for lumbar disc herniation?

Prevalence of Chronic Pain After Spinal Surgery: A Systematic Review and Meta-Analysis

Degenerative disc disease and low back pain are common challenges that persist even after a discectomy. However, characterizations and quantifications of these illnesses from the patients' perspective are insufficient. We aimed to perform a systematic review of the literature and meta-analysis to determine the frequency of chronic pain after spinal surgery. We searched MEDLINE (PubMed), Google Scholar, and the Saudi Digital Library to retrieve research articles describing the frequency of persistent back pain, reoccurring disc herniation, and undergoing another operation following primary lumbar discectomy. We excluded articles that did not disclose the proportion of patients who experienced ongoing back or leg pain for over six months after the operation. We included 16 studies evaluating 85,643 patients. The pooled prevalence of persistent pain was 14.97% (95% confidence interval: 12.38-17.76). With all advancements in technology and operation techniques, many patients (14.97%) still have failed back surgery syndrome. Appropriate preoperative communication and multidisciplinary and coordinated treatment strategies yielded the best results.

Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery

OBJECTIVE

To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France.

METHODS

Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up.

RESULTS

A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%).

CONCLUSIONS

This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.

Selective Chemonucleolysis With Condoliase in Cynomolgus Monkeys

Selective chemonucleolytic effects of condoliase, a glycosaminoglycan degrading enzyme, was investigated histopathologically in cynomolgus monkeys. Condoliase was administered once into the lumber intervertebral disc (IVD), and as a comparative control, chymopapain, a proteolytic enzyme, was administered in a similar manner. Histopathological changes of the IVD and the adjacent vertebral body (VB) were examined at 1 to 26 weeks after administration. Major changes induced by condoliase in the IVD were degenerative and necrotic changes in the nucleus pulposus, annulus fibrosus, cartilaginous endplate (CEP), and epiphyseal growth plate (EGP); focal disappearance of the EGP; and neovascularization and ossification of the CEP. Decreased/necrosis of bone marrow cells with new bone formation was observed in the VB. Cellular regeneration in the IVD was observed as a recovery changes on and after week 4. The changes in the IVD and VB subsided at week 26. Chymopapain induced qualitatively similar but more widely extended changes. The degrees of the changes in the IVD and VB were more severe than those of condoliase, and the changes were exacerbated even at week 26. These results indicated that histopathological changes caused by condoliase were less severe and more selective than those by chymopapain.

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial for Intervertebral Disc Herniation

MINI: We summarized the 10-year outcomes of Spine Patient Outcomes Research Trial for intervertebral disc herniation through a systematic review. The observational cohort 2-year analysis and the as-treated analysis of the randomized control trial at 4 and 8 years showed statistically greater improvements in those patients who were treated surgically.

STUDY DESIGN

We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

OBJECTIVE

We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation.

SUMMARY OF BACKGROUND DATA

The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies.

METHODS

Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes.

RESULTS

The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video.

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 IDH. Results showed significantly greater improvements in patients treated surgically.

LEVEL OF EVIDENCE

3.

Combination of Magnetic Resonance Imaging and Electrophysiological Studies in Lumbar Disc Herniation

Objective We aimed to study the clinical value of magnetic resonance imaging (MRI) and electrophysiological studies in the diagnosis of lumbar disc herniation and in the evaluation of the therapeutic effect of discectomy. Methods In this study, 265 patients with LDH were treated with discectomy after assessment by the Japanese Orthopedic Association (JOA) score, MRI, and electrophysiological studies. All the patients were followed-up for 6 years. The effects of the operation were assessed by determining the angle between the nerve root canal and disc protrusion (AN value), the stenotic ratio of the spinal canal, the width of the lateral recess, motor conduction velocity (MCV), sensory conduction velocity (SCV), and nerve action potential (NAP) before and after operation. Results The AN value, stenotic ratio of the spinal canal, and the width of the lateral recess of protruding intervertebral discs showed significant differences from these values for the patients' unaffected intervertebral discs (P < 0.05). The MCV, SCV, and NAP of the affected limb showed significant differences from these values for the patients' unaffected limbs (P < 0.05). In all the patients the values for these indicators showed significant differences before and after operation (P < 0.05). Conclusion MRI and electrophysiological studies can be used in the diagnosis of lumbar disc herniation, and in the evaluation of the effect of surgery.

More nerve root injuries occur with minimally invasive lumbar surgery: Let's tell someone

Background:

In a recent study entitled: “More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion (XLIF): A review”, Epstein documented that more nerve root injuries occurred utilizing minimally invasive surgery (MIS) versus open lumbar surgery for diskectomy, decompression of stenosis (laminectomy), and/or fusion for instability.

Methods:

In large multicenter Spine Patient Outcomes Research Trial reviews performed by Desai et al., nerve root injury with open diskectomy occurred in 0.13–0.25% of cases, occurred in 0% of laminectomy/stenosis with/without fusion cases, and just 2% for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion.

Results:

In another MIS series performed largely for disc disease (often contained nonsurgical disc herniations, therefore unnecessary procedures) or spondylolisthesis, the risk of root injury was 2% for transforaminal lumbar interbody fusion (TLIF) versus 7.8% for posterior lumbar interbody fusion (PLIF). Furthermore, the high frequencies of radiculitis/nerve root/plexus injuries incurring during anterior lumbar interbody fusions (ALIF: 15.8%) versus extreme lumbar interbody fusions (XLIF: 23.8%), addressing disc disease, failed back surgery, and spondylolisthesis, were far from acceptable.

Conclusions:

The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques (TLIF/PLIF/ALIF/XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?

More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review

BACKGROUND

In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis.

METHODS

Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%.

RESULTS

Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits.

CONCLUSIONS

This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients?

Unintended durotomy in lumbar degenerative spinal surgery: a 10-year systematic review of the literature

OBJECT

Unintended durotomy is a common occurrence during lumbar spinal surgery, particularly in surgery for degenerative spinal conditions, with the reported incidence rate ranging from 0.3% to 35%. The authors performed a systematic literature review on unintended lumbar spine durotomy, specifically aiming to identify the incidence of durotomy during spinal surgery for lumbar degenerative conditions. In addition, the authors analyzed the incidence of durotomy when minimally invasive surgical approaches were used as compared with that following a traditional midline open approach.

METHODS

A MEDLINE search using the term “lumbar durotomy” (under the 2015 medical subject heading [MeSH] “cerebrospinal fluid leak”) was conducted on May 13, 2015, for English-language medical literature published in the period from January 1, 2005, to May 13, 2015. The resulting papers were categorized into 3 groups: 1) those that evaluated unintended durotomy rates during open-approach lumbar spinal surgery, 2) those that evaluated unintended durotomy rates during minimally invasive spine surgery (MISS), and 3) those that evaluated durotomy rates in comparable cohorts undergoing MISS versus open-approach lumbar procedures for similar lumbar pathology.

RESULTS

The MEDLINE search yielded 116 results. A review of titles produced 22 potentially relevant studies that described open surgical procedures. After a thorough review of individual papers, 19 studies (comprising 15,965 patients) pertaining to durotomy rates during open-approach lumbar surgery were included for analysis. Using the Oxford Centre for Evidence-Based Medicine (CEBM) ranking criteria, there were 7 Level 3 prospective studies and 12 Level 4 retrospective studies. In addition, the authors also included 6 studies (with a total of 1334 patients) that detailed rates of durotomy during minimally invasive surgery for lumbar degenerative disease. In the MISS analysis, there were 2 prospective and 4 retrospective studies. Finally, the authors included 5 studies (with a total of 1364 patients) that directly compared durotomy rates during open-approach versus minimally invasive procedures. Studies of open-approach surgery for lumbar degenerative disease reported a total of 1031 durotomies across all procedures, for an overall durotomy rate of 8.11% (range 2%–20%). Prospectively designed studies reported a higher rate of durotomy than retrospective studies (9.57% vs 4.32%, p = 0.05). Selected MISS studies reported a total of 93 durotomies for a combined durotomy rate of 6.78%. In studies of matched cohorts comparing open-approach surgery with MISS, the durotomy rates were 7.20% (34 durotomies) and 7.02% (68), respectively, which were not significantly different.

CONCLUSIONS

Spinal surgery for lumbar degenerative disease carries a significant rate of unintended durotomy, regardless of the surgical approach selected by the surgeon. Interpretation of unintended durotomy rates for lumbar surgery is limited by a lack of prospective and cohort-matched controlled studies.

Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes

BACKGROUND

Long-term postdiscectomy degenerative disc disease and low back pain is a well-recognized disorder; however, its patient-centered characterization and quantification are lacking.

QUESTIONS/PURPOSES

We performed a systematic literature review and prospective longitudinal study to determine the frequency of recurrent back pain after discectomy and quantify its effect on patient-reported outcomes (PROs).

METHODS

A MEDLINE search was performed to identify studies reporting on the frequency of recurrent back pain, same-level recurrent disc herniation, and reoperation after primary lumbar discectomy. After excluding studies that did not report the percentage of patients with persistent back or leg pain more than 6 months after discectomy or did not report the rate of same level recurrent herniation, 90 studies, which in aggregate had evaluated 21,180 patients, were included in the systematic review portion of this study. For the longitudinal study, all patients undergoing primary lumbar discectomy between October 2010 and March 2013 were enrolled into our prospective spine registry. One hundred fifteen patients were more than 12 months out from surgery, 103 (90%) of whom were available for 1-year outcomes assessment. PROs were prospectively assessed at baseline, 3 months, 1 year, and 2 years. The threshold of deterioration used to classify recurrent back pain was the minimum clinically important difference in back pain (Numeric Rating Scale Back Pain [NRS-BP]) or Disability (Oswestry Disability Index [ODI]), which were 2.5 of 10 points and 20 of 100 points, respectively.

RESULTS SYSTEMATIC REVIEW

The proportion of patients reporting short-term (6-24 months) and long-term (> 24 months) recurrent back pain ranged from 3% to 34% and 5% to 36%, respectively. The 2-year incidence of recurrent disc herniation ranged from 0% to 23% and the frequency of reoperation ranged from 0% to 13%.

PROSPECTIVE STUDY

At 1-year and 2-year followup, 22% and 26% patients reported worsening of low back pain (NRS: 5.3 ± 2.5 versus 2.7 ± 2.8, p < 0.001) or disability (ODI%: 32 ± 18 versus 21 ± 18, p < 0.001) compared with 3 months.

CONCLUSIONS

In a systematic literature review and prospective outcomes study, the frequency of same-level disc herniation requiring reoperation was 6%. Two-year recurrent low back pain may occur in 15% to 25% of patients depending on the level of recurrent pain considered clinically important, and this leads to worse PROs at 1 and 2 years postoperatively.

Scanning pattern of diffusion tensor tractography and an analysis of the morphology and function of spinal nerve roots

Radiculopathy, commonly induced by intervertebral disk bulging or protrusion, is presently diagnosed in accordance with clinical symptoms because there is no objective quantitative diagnostic criterion. Diffusion tensor magnetic resonance imaging and diffusion tensor tractography revealed the characterization of anisotropic diffusion and displayed the anatomic form of nerve root fibers. This study included 18 cases with intervertebral disc degeneration-induced unilateral radiculopathy. Magnetic resonance diffusion tensor imaging was creatively used to reveal the scanning pattern of fiber tracking of the spinal nerve root. A scoring system of nerve root morphology was used to quantitatively assess nerve root morphology and functional alteration after intervertebral disc degeneration. Results showed that after fiber tracking, compared with unaffected nerve root, fiber bundles gathered together and interrupted at the affected side. No significant alteration was detected in the number of fiber bundles, but the cross-sectional area of nerve root fibers was reduced. These results suggest that diffusion tensor magnetic resonance imaging-based tractography can be used to quantitatively evaluate nerve root function according to the area and morphology of fiber bundles of nerve roots.