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Cômes PC, Gavotto A, Zouakia Z, Lonjon G, Amelot A, Edgard-Rosa G, Debono B. Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice. Global Spine J 2024:21925682241249102. [PMID: 38652921 DOI: 10.1177/21925682241249102] [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: 04/25/2024] Open
Abstract
STUDY DESIGN Retrospective multicenter cohort study. OBJECTIVE Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. METHODS This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. RESULTS The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. CONCLUSIONS The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.
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Affiliation(s)
- Pierre-Cyril Cômes
- Centre Francilien du Dos, Clinique des Franciscaines, Versailles, France
- Neurosurgical department, Foch Hospital, Suresnes, France
| | - Amandine Gavotto
- University Hospital Nice, Unité de Chirurgie Rachidienne, Nice, France
| | - Zineb Zouakia
- Service de recherche clinique, Hôpital Fondation A. de Rotschild, Paris, France
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean-Sud de France, Santé Cite, Paris, France
| | - Aymeric Amelot
- Département de neurochirurgie, University Hospital of Tours, Tours, France
| | - Grégory Edgard-Rosa
- Centre de Chirurgie Vertébrale (CCV) MONTPELLIER, Clinique du Parc, Castelnau-le-Lez, France
| | - Bertrand Debono
- Centre Francilien du Dos, Clinique des Franciscaines, Versailles, France
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Sastry RA, Chen JS, Shao B, Weil RJ, Chang KE, Maynard K, Syed SH, Zadnik Sullivan PL, Camara JQ, Niu T, Sampath P, Telfeian AE, Oyelese AA, Fridley JS, Gokaslan ZL. Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019. JAMA Netw Open 2023; 6:e2326357. [PMID: 37523184 PMCID: PMC10391306 DOI: 10.1001/jamanetworkopen.2023.26357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Importance Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population. Objective To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019. Design, Setting, and Participants This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023. Main Outcome and Measure The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone. Results Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001). Conclusions and Relevance In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Jia-Shu Chen
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Robert J Weil
- Department of Neurosurgery, Brain and Spine, Southcoast Health, Dartmouth, Massachusetts
| | - Ki-Eun Chang
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ken Maynard
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sohail H Syed
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Patricia L Zadnik Sullivan
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Joaquin Q Camara
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
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Kim HS, Wu PH, Jie Chin BZ, Jang IT. Systematic Review of Current Literature on Clinical Outcomes of Uniportal Interlaminar Contralateral Endoscopic Lumbar Foraminotomy for Foraminal Stenosis. World Neurosurg 2022; 168:392-397. [DOI: 10.1016/j.wneu.2022.04.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
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Won YI, Kim CH, Park HP, Chung SG, Yuh WT, Kwon SW, Yang SH, Lee CH, Choi Y, Park SB, Rhee JM, Kim KT, Chung CK. A cost-utility analysis between decompression only and fusion surgery for elderly patients with lumbar spinal stenosis and sagittal imbalance. Sci Rep 2022; 12:20408. [PMID: 36437360 PMCID: PMC9701767 DOI: 10.1038/s41598-022-24784-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
Lumbar spinal stenosis (LSS) and sagittal imbalance are relatively common in elderly patients. Although the goals of surgery include both functional and radiological improvements, the criteria of correction may be too strict for elderly patients. If the main symptom of patients is not forward-stooping but neurogenic claudication or pain, lumbar decompression without adding fusion procedure may be a surgical option. We performed cost-utility analysis between lumbar decompression and lumbar fusion surgery for those patients. Elderly patients (age > 60 years) who underwent 1-2 levels lumbar fusion surgery (F-group, n = 31) or decompression surgery (D-group, n = 40) for LSS with sagittal imbalance (C7 sagittal vertical axis, C7-SVA > 40 mm) with follow-up ≥ 2 years were included. Clinical outcomes (Euro-Quality of Life-5 Dimensions, EQ-5D; Oswestry Disability Index, ODI; numerical rating score of pain on the back and leg, NRS-B and NRS-L) and radiological parameters (C7-SVA; lumbar lordosis, LL; the difference between pelvic incidence and lumbar lordosis, PI-LL; pelvic tilt, PT) were assessed. The quality-adjusted life year (QALY) and incremental cost-effective ratio (ICER) were calculated from a utility score of EQ-5D. Postoperatively, both groups attained clinical and radiological improvement in all parameters, but NRS-L was more improved in the F-group (p = 0.048). ICER of F-group over D-group was 49,833 US dollars/QALY. Cost-effective lumbar decompression may be a recommendable surgical option for certain elderly patients, despite less improvement of leg pain than with fusion surgery.
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Affiliation(s)
- Young Il Won
- grid.254230.20000 0001 0722 6377Department of Neurosurgery, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, 30099 Republic of Korea
| | - Chi Heon Kim
- grid.412484.f0000 0001 0302 820XDepartment of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.412484.f0000 0001 0302 820XDepartment of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Hee-Pyoung Park
- grid.31501.360000 0004 0470 5905Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine and Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Sun Gun Chung
- grid.31501.360000 0004 0470 5905Department of Rehabilitation Medicine, Seoul National University College of Medicine and Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Woon Tak Yuh
- grid.488450.50000 0004 1790 2596Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450 Republic of Korea
| | - Shin Won Kwon
- Department of Neurosurgery, Incheon Veterans Hospital, 138, Inju-daero, Michuhol-gu, Incheon, 22182 Republic of Korea
| | - Seung Heon Yang
- grid.31501.360000 0004 0470 5905Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.412480.b0000 0004 0647 3378Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Chang-Hyun Lee
- grid.412484.f0000 0001 0302 820XDepartment of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Yunhee Choi
- grid.412484.f0000 0001 0302 820XDivision of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Sung Bae Park
- grid.31501.360000 0004 0470 5905Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.412479.dDepartment of Neurosurgery, Seoul National University Boramae Hospital, Boramae Medical Center 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061 Republic of Korea
| | - John M. Rhee
- grid.189967.80000 0001 0941 6502Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Kyoung-Tae Kim
- grid.411235.00000 0004 0647 192XDepartment of Neurosurgery, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944 Republic of Korea ,grid.258803.40000 0001 0661 1556Department of Neurosurgery, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 41944 Republic of Korea
| | - Chun Kee Chung
- grid.412484.f0000 0001 0302 820XDepartment of Neurosurgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Brain and Cognitive Sciences, Seoul National University, 101, 1, Gwanak-ro, Gwanak-gu, Seoul, Republic of Korea
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Biomechanical Effect of Disc Height on the Components of the Lumbar Column at the Same Axial Load: A Finite-Element Study. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7069448. [PMID: 36330359 PMCID: PMC9626214 DOI: 10.1155/2022/7069448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
Intervertebral discs are fibrocartilage structures, which play a role in buffering the compression applied to the vertebral bodies evenly while permitting limited movements. According to several previous studies, degenerative changes in the intervertebral disc could be accelerated by factors, such as aging, the female sex, obesity, and smoking. As degenerative change progresses, the disc height could be reduced due to the dehydration of the nucleus pulposus. This study aimed to quantitatively analyze the pressure that each structure of the spine receives according to the change in the disc height and predict the physiological effect of disc height on the spine. We analyzed the biomechanical effect on spinal structures when the disc height was decreased using a finite-element method investigation of the lumbar spine. Using a 3D FE model, the degree and distribution of von-Mises stress according to the disc height change were measured by applying the load of four different motions to the lumbar spine. The height was changed by dividing the anterior and posterior parts of the disc, and analysis was performed in the following four motions: flexion, extension, lateral bending, and axial rotation. Except for a few circumstances, the stress applied to the structure generally increased as the disc height decreased. Such a phenomenon was more pronounced when the direction in which the force was concentrated coincided with the portion where the disc height decreased. This study demonstrated that the degree of stress applied to the spinal structure generally increases as the disc height decreases. The increase in stress was more prominent when the part where the disc height was decreased and the part where the moment was additionally applied coincided. Disc height reduction could accelerate degenerative changes in the spine. Therefore, eliminating the controllable risk factors that cause disc height reduction may be beneficial for spinal health.
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Kwon SY, Shim JH, Kim YH, Lim CS, An SB, Han I. Efficacy for Whitlockite for Augmenting Spinal Fusion. Int J Mol Sci 2021; 22:12875. [PMID: 34884680 PMCID: PMC8657587 DOI: 10.3390/ijms222312875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 01/21/2023] Open
Abstract
Whitlockite (WH) is the second most abundant inorganic component of human bone, accounting for approximately 25% of bone tissue. This study investigated the role of WH in bone remodeling and formation in a mouse spinal fusion model. Specifically, morphology and composition analysis, tests of porosity and surface area, thermogravimetric analysis, an ion-release test, and a cell viability test were conducted to analyze the properties of bone substitutes. The MagOss group received WH, Group A received 100% beta-tricalcium phosphate (β-TCP), Group B received 100% hydroxyapatite (HAp), Group C received 30% HAp/70% β-TCP, and Group D received 60% HAp/40% β-TCP (n = 10 each). All mice were sacrificed 6 weeks after implantation, and micro-CT, hematoxylin and eosin (HE) staining, and Masson trichome (MT) staining and immunohistochemistry were performed. The MagOss group showed more homogeneous and smaller grains, and nanopores (<500 nm) were found in only the MagOss group. On micro-CT, the MagOss group showed larger fusion mass and better graft incorporation into the decorticate mouse spine than other groups. In the in vivo experiment with HE staining, the MagOss group showed the highest new bone area (mean: decortication group, 9.50%; A, 15.08%; B, 15.70%; C, 14.76%; D, 14.70%; MagOss, 22.69%; p < 0.0001). In MT staining, the MagOss group demonstrated the highest new bone area (mean: decortication group, 15.62%; A, 21.41%; B, 22.86%; C, 23.07%; D, 22.47%; MagOss, 26.29%; p < 0.0001). In an immunohistochemical analysis for osteocalcin, osteopontin, and CD31, the MagOss group showed a higher positive area than other groups. WH showed comparable bone conductivity to HAp and β-TCP and increased new bone formation. WH is likely to be used as an improved bone substitute with better bone conductivity than HAp and β-TCP.
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Affiliation(s)
- Su Yeon Kwon
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si 13496, Gyeonggi-do, Korea; (S.Y.K.); (C.S.L.)
| | - Jung Hee Shim
- R&D Center, OSFIRM Co., Ltd., Seongnam-si 13620, Gyeonggi-do, Korea; (J.H.S.); (Y.H.K.)
| | - Yu Ha Kim
- R&D Center, OSFIRM Co., Ltd., Seongnam-si 13620, Gyeonggi-do, Korea; (J.H.S.); (Y.H.K.)
| | - Chang Su Lim
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si 13496, Gyeonggi-do, Korea; (S.Y.K.); (C.S.L.)
| | - Seong Bae An
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si 13496, Gyeonggi-do, Korea; (S.Y.K.); (C.S.L.)
| | - Inbo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si 13496, Gyeonggi-do, Korea; (S.Y.K.); (C.S.L.)
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