Decompressive lumbar laminectomy for spinal stenosis

Research Progress on the Posterior Midline Lumbar Spinous Process-Splitting Approach

The traditional posterior median approach laminectomy is widely used for lumbar decompression. However, the bilateral dissection of paraspinal muscles during this procedure often leads to postoperative muscle atrophy, chronic low back pain, and other complications. The posterior midline spinous process-splitting approach (SPSA) offers a significant advantage over the traditional approach by minimizing damage to the paraspinal muscles. SPSA reduces the incidence of muscle atrophy and chronic low back pain while maintaining the integrity of the posterior spinal structures. The technique involves longitudinal splitting of the spinous process, which allows for adequate access to the lamina for decompression without detaching the paraspinal muscles. As a result, it provides a clearer surgical field and facilitates muscle preservation, which reduces the risk of postoperative complications. Additionally, SPSA requires only standard surgical instruments, making it accessible in most surgical settings. This paper reviews the anatomical considerations, surgical techniques, and clinical applications of the SPSA, highlighting its effectiveness in reducing muscle atrophy and improving recovery outcomes. The paper also discusses its potential in treating conditions such as lumbar spinal stenosis, disc herniation, and spondylolisthesis. Furthermore, it emphasizes the need for future research to establish the long-term benefits of SPSA and refine surgical techniques. The results suggest that SPSA is a promising alternative to traditional approaches, with better outcomes in terms of muscle preservation and overall recovery.

The Remote Intradural Migration of Polyethylene Glycol-Based Hydrogel Sealant Following Lumbar Laminectomy: A Case Report

Background/Objectives: Synthetic polyethylene glycol (PEG)-based hydrogel sealants, such as Adherus, are commonly used in spinal surgeries to achieve watertight dural closure and prevent cerebrospinal fluid (CSF) leaks. This case report describes an unusual instance of suspected hydrogel sealant migration resulting in an intradural collection at a spinal level remote from the original surgery. Methods: A 57-year-old female with a history of osteoarthritis and prediabetes underwent a minimally invasive L5-S1 laminectomy for the removal of an epidural abscess causing cauda equina and S1 nerve root compression. During the procedure, a dural puncture occurred, which was repaired using Duragen (collagen matrix) and Adherus (synthetic PEG hydrogel sealant). Postoperatively, the patient developed urinary retention and new bilateral posterior leg pain. An MRI on postoperative day four revealed a new peripherally enhancing dorsal intradural collection at the L2 level, causing significant thecal sac narrowing and compression of the cauda equina nerve roots, suggestive of migration of the hydrogel sealant used during surgery. Conservative management was adopted. Results: The patients symptoms gradually resolved. Follow-up imaging at five months showed resolution of the intradural collection, with residual intradural inflammatory changes and arachnoiditis. Conclusions: While PEG-based hydrogel sealants like Adherus are effective in preventing CSF leaks, they can, in rare instances, migrate and cause remote intradural collections with neurological symptoms. Surgeons should exercise meticulous application techniques, thoroughly document the use of sealants, and maintain vigilant postoperative monitoring to mitigate these risks.

Viscoelastic modeling based force control framework for enhancing operation safety of soft tissue for orthopedic surgical robots

In robot-assisted laminectomy, precise control of touch force on the spinal cord during the dissection of ossified ligaments is critical to prevent dura mater tearing and ensure surgical safety. However, the complex viscoelastic characteristics of tissue at the lesion site pose a significant challenge for accurately applying touch force. This paper proposes a safe touch force servo framework based on tissue model identification and preoperative optimization of the force controller. First, a soft tissue model is established using elastic and viscoelastic elements, and the transfer function from tissue deformation to touch force is derived. Subsequently, the path and parameters of a safe pre-touch are designed, and force information required for tissue model identification is obtained through the pre-touch experiment. The model order and specific parameter values are then identified using a differential evolution algorithm. Next, force control simulation is conducted based on the identified model, and a specifically designed loss function is introduced to achieve preoperative tuning of the force controller. Finally, step force control experiments on sheep spines validate the effectiveness of the proposed method. This paper provides a safe and available touch motion control framework that can be expandable to impose precise force on various vulnerable soft tissues, with the potential for widespread application.

Does Spinal Surgery in Elderly Patients (Over 80 Years-Old) Lead to More Early Post-Operative Complications Than Lower Limb Prosthetic Surgery?

Purpose: Patients and surgeons may be reluctant on spinal surgery over 80 years old, fearing medical complications despite the possible improvement on quality of life. However, fewer reservations for lower limb prosthetic surgery (LLPS) seem to be arisen in this population. Is spinal surgery after 80 years-old responsible of more complications than lower limb surgery? Methods: The consecutive files of 164 patients over 80 years that had spinal surgery or LLPS were analyzed. The data collected pre-operatively were demographic, clinical and post-operatively the number and types of medical complications and length of stay. Results: The mean number of medical complications was 1.11 ± 0.6 [0-6] for spinal surgery and 1.09 ± 1.0 [0-3] for LLPS, (p = 0,87). The length of stay in orthopedic unit was comparable between the two groups: 10.7 ± 4.9 days [2-36] for SS and 10.7 ± 3.0 days [5-11] for LLPS (p = 0,96). Conclusion: The global rate of peri-operative complications and the length of hospital stay were similar between spinal surgery and lower limb prosthetic surgery. These results may be explained by the rising cooperation between geriatric specialist and surgeons and the development of mini-invasive surgical technics, diminishing the early post-operative complication rates.

Assessment of Analgesic Efficacy of Bilateral Lumbar Erector Spinae Plane Block for Postoperative Pain following Lumbar Laminectomy: A Single-Blind, Randomized Clinical Trial

Background

The erector spinae plane (ESP) block is a novel approach to minimizing postoperative pain. We investigated the efficacy and side effects of the ultrasonography-guided bilateral ESP block in reducing pain in the first 24 hours after lumbar laminectomy.

Materials and Methods

We conducted a single-blind (statistical analyst and those responsible for recording patient information postoperation were unaware of the study groups) randomized clinical trial on 50 patients aged 18 to 65 with American Society of Anesthesiology (ASA) class I or II physical status scheduled for lumbar laminectomy surgery at Shahid Chamran Hospital, Shiraz, Iran. Patients were randomly allocated to the ESP block (26 participants) or control (24 participants) group. A bilateral ESP block was administered to patients in the first group before general anesthesia, which was provided identically to both groups. The postoperative time to the first request of analgesia, pain score, total opioid use, side effects, and patient satisfaction were compared between the groups.

Results

Compared with the control group, patients in the ESP block group had significantly more postoperative pain relief in the first hour and until 24 hours (P < 0.05). The total opioid consumption was lower in the ESP block group (P < 0.001). However, the ESP block led to a higher rate of urinary retention (P = 0.008).

Conclusion

The bilateral ESP block effectively reduces postoperative pain following lumbar laminectomy, minimizing the need for narcotics. Further research is needed to delineate ways to reduce urinary retention as its main complication. This trial is registered with IRCT20100127003213N6.

Perioperative risk factors related to complications of lumbar spine fusion surgery in elderly patients

PURPOSE

To analyze the perioperative risk factors related to lumbar spine fusion surgery in elderly patients.

METHODS

202 elderly patients (age range 77-92 years old) who have underwent lumbar spinal fusion surgeries between January 2019 and June 2021 were retrospectively investigated. Information of age, sex, comorbidity, fixation segments, operation time, surgical blood loss and perioperative complications during hospitalization were collected. Risk factors for complications were analyzed. Student's t-test, chi-square test, Mann-Whitney U‑test and multivariate generalized linear models were used.

RESULTS

In this study, 31 patients presented complications (15.3%) in these elderly patients with an average age of 79.1 years, including 1 patient with intraoperative complication and 30 patients with postoperative complications; and 2 out of 31 patients (1%) died. The elderly patients were divided into group A (24 patients) with major postoperative complications and group B (178 patients) without major postoperative complications. Major postoperative complications were significantly associated with age (univariate analysis, t = 3.92, P < 0.001; multivariate analysis, OR = 1.323, 95%CI 1.126-1.554, P = 0.001), but not significantly associated with other factors tested (sex, comorbidity, fixation segments, operation time, surgical blood loss). Then 173 patients (range 77-81 years) were selected and the rate of major postoperative complications of each age from 78 to 81 years was compared with that of 77 years patients, respectively. We found that the ratios of complications at 80 years (OR = 10.000, P = 0.019) and 81 years (OR = 10.000, P = 0.009) were higher than the ratio at 77 years.

CONCLUSIONS

Although with great progress of medical technology, increasing age was still the independent risk factor for major postoperative complications in elderly patients undergoing lumbar spinal fusion surgery. As for the incidence of major postoperative complications, 80 and 81 years old patients was 10 folds higher than that of 77 years old patients, reminding us to pay more attention to 80 years old and even older patients.

Differentiating Lumbar Spinal Etiology from Peripheral Plexopathies

Clinicians have managed and treated lower back pain since the earliest days of practice. Historically, lower back pain and its accompanying symptoms of radiating leg pain and muscle weakness have been recognized to be due to any of the various lumbar spine pathologies that lead to the compression of the lumbar nerves at the root, the most common of which is the radiculopathy known as sciatica. More recently, however, with the increased rise in chronic diseases, the importance of differentially diagnosing a similarly presenting pathology, known as lumbosacral plexopathy, cannot be understated. Given the similar clinical presentation of lumbar spine pathologies and lumbosacral plexopathies, it can be difficult to differentiate these two diagnoses in the clinical setting. Resultingly, the inappropriate diagnosis of either pathology can result in ineffective clinical management. Thus, this review aims to aid in the clinical differentiation between lumbar spine pathology and lumbosacral plexopathy. Specifically, this paper delves into spine and plexus anatomy, delineates the clinical assessment of both pathologies, and highlights powerful diagnostic tools in the hopes of bolstering appropriate diagnosis and treatment. Lastly, this review will describe emerging treatment options for both pathologies in the preclinical and clinical realms, with a special emphasis on regenerative nerve therapies.

Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection

Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.

Frailty is an important predictor of 30-day morbidity in patients treated for lumbar spondylolisthesis using a posterior surgical approach

BACKGROUND CONTEXT

Traditionally, a nonoperative approach has been favored for elderly patients with lumbar spondylolisthesis due to a perceived higher risk of morbidity with surgery. However, most studies have used an arbitrary age cut-off to define "elderly" and this research has yielded conflicting results.

PURPOSE

The purpose of this study was to investigate the impact of frailty on morbidity after surgery for degenerative lumbar spondylolisthesis treated with a posterior approach.

STUDY DESIGN

A retrospective cohort study was performed.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, with years 2010 to 2018 included in this study. Patients who received posterior lumbar spine decompression with or without single level posterior instrumented fusion for degenerative lumbar spondylolisthesis were included. Patients who received anterior and/or lateral approaches were excluded.

OUTCOME MEASURES

The primary outcome was Clavien-Dindo grade IV complication. Secondary outcomes were readmission, reoperation, and discharge to location other than home.

METHODS

Patient demographics and comorbidities were extracted. Logistic regression analysis was performed to investigate the association between outcomes and the Modified Frailty Index-5, adjusting for age, gender, body mass index, smoking status, and surgical procedure performed. A sub-analysis was done to assess the effect of frailty in three different age groups (18-45 years, 46-65 years, and >65 years) for the two surgical cohorts.

RESULTS

There were 15,658 patients in this study. The mean age was 62.5 years. Approximately 70% of the patients received decompression with fusion. Frailty was significantly associated with an increased risk of major complication, unplanned readmission, reoperation, and non-home discharge. The risk increased with increasing frailty. For patients who received decompression, frailty was associated with a higher risk of readmission and non-home discharge in patients >65 years. For patients who received decompression and fusion, frailty was associated with a higher risk of complications, readmission, and non-home discharge in patients >65 years.

CONCLUSIONS

Frailty is independently associated with a higher risk of morbidity after posterior surgery in patients with lumbar spondylolisthesis, especially in patients older than 65. These data are of significance to clinicians in planning treatment for these patients.

Elective Lumbar Spine Surgery in Depressed Patients: Is it Worth it?

BACKGROUND

The objective of this study is to compare surgical results (pain, function, and satisfaction) between a group of depressed patients and a nondepressed group who had been operated on for a degenerative lumbar condition.

METHODS

Prospective observational study. Preoperative pain (lumbar and radicular visual analog scale [VAS]), function (Oswestry Disability Index [ODI]), and depression (Zung depression scale) data were collected in patients listed to be operated on for a lumbar degenerative condition. One year postoperatively, ODI and VAS data were collected again as well as a satisfaction question (are you satisfied with the surgical results? Yes/no).

RESULTS

Ninety-seven patients were included in the study, 78 nondepressed patients (80.4%) and 19 depressed patients (19.6%). Preoperatively, depressed patients had more lumbar pain (P = .00) and more functional limitation (P = .01) than nondepressed patients. One year postoperatively, depressed patients had more radicular pain (P = .029) and more functional limitation (P = .03) than non-depressed patients. The overall improvement of pain and function was similar between both groups (not significant). Seventy percent of depressed patients and 80% of nondepressed patients were satisfied with the surgical outcome (P = .52) 1 year postoperatively.

CONCLUSION

Depressed patients experience the same overall level of improvement as nondepressed patients, despite having more pain and functional limitation preoperatively and 1 year after elective lumbar spine surgery than nondepressed patients. The level of satisfaction does not differ significantly between the two groups.

LEVEL OF EVIDENCE

2.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Biomechanical effects of laminectomies in the human lumbar spine: a finite element study

BACKGROUND CONTEXT

Previous studies have analyzed the effect of laminectomy on intervertebral disc (IVD), facet-joint-forces (FJF), and range of motion (ROM), while only two have specifically reported stresses at the pars interarticularis (PI) with posterior element resection. These studies have been performed utilizing a single subject, questioning their applications to a broader population.

PURPOSE

We investigate the effect of graded PI resection in a three-dimensional manner on PI stress to provide surgical guidelines for avoidance of iatrogenic instability following lumbar laminectomy. Additionally, quantified FJF and IVD stresses can provide further insight into the development of adjacent segment disease.

STUDY DESIGN

Biomechanical finite element (FE) method investigation of the lumbar spine.

METHODS

FE models of the lumbar spine of three subjects were created using the open-source finite element software, FEBio. Single-level laminectomy, two-level laminectomy, and ventral-to-dorsal PI resection simulations were performed with varying degrees of PI resection from 0% to 75% of the native PI. These models were taken through cardinal ROM under standard loading conditions and PI stresses, FJF, IVD stresses, and ROM were analyzed.

RESULTS

The three types of laminectomy simulated in this study showed a nonlinear increase in PI stress with increased bone resection. Axial rotation generated the most stress at the PI followed by flexion, extension and lateral bending. At 75% bone resection all three types of laminectomy produced PI stresses that were near the ultimate strength of human cortical bone during axial rotation. FJF decreased with increased bone resection for the three laminectomies simulated. This was most notable in axial rotation followed by extension and lateral bending. IVD stresses varied greatly between the nonsurgical models and likewise the effect of laminectomy on IVD stresses varied between subjects. ROM was mostly unaffected by the laminectomies performed in this study.

CONCLUSIONS

Regarding the risk of iatrogenic spondylolisthesis, the combined results are sufficient evidence to suggest surgeons should be particularly cautious when PI resection exceeds 50% bone resection for all laminectomies included in this study. Lastly, the effects seen in FJF and IVD stresses indicate the degree to which the remainder of the spine must experience compensatory biomechanical changes as a result of the surgical intervention.

Is Older Age a Contraindication for Single-Level Transforaminal Lumbar Interbody Fusion?

STUDY DESIGN

Retrospective cohort.

PURPOSE

This study's primary objective was to compare the clinico-radiological outcomes and incidence of perioperative complications of transforaminal lumbar interbody fusion (TLIF) at lower lumbar levels for elderly and younger patients. The secondary objective was to evaluate the effect of age on clinical outcomes and patient satisfaction in the two groups.

OVERVIEW OF LITERATURE

The lumbar interbody fusion surgery in elder age has been reported to produce a higher complication rate and suboptimal results. Literature evaluating efficacy and safety of TLIF in elderly population is scanty. The effect of age on clinical outcome and the overall patient satisfaction after TLIF has been understudied.

METHODS

This retrospective study was conducted from 2011 to 2017 with 121 patients, who underwent TLIF and were divided into two cohorts based on age (group A, >65 years and group B, <65 years). Perioperative clinical/radiological parameters, postoperative complications, and satisfactory outcomes were evaluated in both groups. A statistical analysis between two matched groups was performed with logistic regression analysis and Student t-test.

RESULTS

The mean age was 73.8±4.5 years in group A and 47.3±12.7 years in group B. There was no statistical difference in surgical time (p=0.15), mobilization, or hospital stay (p=0.15) between the two groups. There were no statistically significant differences noted in the Oswestry Disability Index, Visual Analog Scale, or Wang's outcome score between the two groups at final follow-up. Postoperative complications not affecting outcome were common in the elderly group, but there was no statistically significant difference noted among neurological or cardiopulmonary events between the two groups.

CONCLUSIONS

In judiciously selected patients with proper preoperative risk assessment and optimized medical co-morbidities, TLIF surgery can have successful results, in terms of clinical outcome and satisfaction, in the elderly. Older age should not be a contraindication for TLIF in patients with degenerative lumbar disease.

Are degenerative spondylolisthesis and further slippage postoperatively really issues in spinal stenosis surgery?

Background and aims Opinions diverge concerning the prognostic importance of preoperative degenerative spondylolisthesis in patients with lumbar spinal stenosis, as well as the significance of further slippage post-operatively following decompression alone. However, a slip is only one among several factors related to the topic, e.g. duration and intensity of back and leg pain, pre-operative walking ability, number of levels operated and not least the experience of the surgeon. Our aim was to take all of the above-mentioned factors into consideration when analysing the patients' clinical outcome, reported as Change in back pain, Change in leg pain, Overall satisfaction and Change in walking ability, with special emphasis on the possible importance of pre- and/or post-operative degenerative spondylolisthesis. Methods We studied 200 consecutive patients, mean follow-up time 81 months (range 62-108). Before treatment and on the follow-up occasion all patients answered the SF-36 questionnaire and assessed their back and leg pain on a visual analogue scale (VAS). At follow-up the patients were asked about possible changes in back and leg pain (completely free, much better, somewhat better, unchanged, somewhat worse, much worse) and whether they were; satisfied with the outcome, in doubt or not satisfied. Before treatment and at follow-up the presence or not of degenerative spondylolisthesis was determined in the lateral view on a plain X-ray or MRI. By use of a microsurgical technique decompression was achieved in all patients by bilateral laminotomy not sparing the midline ligaments, irrespective of a degenerative spondylolisthesis or not. Eight surgeons with different surgical experience performed the operations. Four separate multivariate analyses were conducted, one for each clinical outcome. The Lasso method was used for variable selection and multiple imputation was applied to handle missing values. Results At follow-up 78.5% of the patients were completely satisfied with the outcome. Minimal clinical important difference (MCID) was achieved for 69% of the patients. Before surgery 28 patients were able to walk more than 1 km compared to 111 at follow-up. The reoperation rate at 6.8 years was 12% further decompressions and 2.5% fusions at the index level. Post-operative slippage was equally common in patients with and without a preoperative slip (around 30%). There were no notable differences in outcome in patients with and without a preoperative slip and no effect of further slippage at the index or another level post-operatively. Nor could the statistical analysis show any of the other covariates (age, gender, duration and intensity of back and leg pain, pre-operative walking ability or number of levels operated) to be of statistically significant importance for predicting the outcome. In the univariate statistical analysis differences were found between the patients of individual surgeons regarding satisfaction, pain improvement, and reoperation rates in favour of surgical experience, which were, however, not statistically significant in the multivariate analysis. Conclusions None of the covariates, including pre-operative spondylolisthesis and further slippage post-operatively, were statistically significant for predicting the clinical outcome. Implication Our results provide no evidence for adding fusion to the decompression.

The Effect of Older Age on the Perioperative Outcomes of Spinal Fusion Surgery in Patients With Lumbar Degenerative Disc Disease With Spondylolisthesis: A Propensity Score-Matched Analysis

BACKGROUND

Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults.

OBJECTIVE

To evaluate the impact of advanced age on the safety of LSF for DS.

METHODS

Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (&lt;70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age &lt;70 and ≥70 groups.

RESULTS

The study cohort consisted of 2238 patients (n = 1119, age &lt;70; n = 1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P = .009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P &lt; .001) or skilled care (OR 3.66, P &lt; .001) facility, rather than directly home (OR 0.25, P &lt; .001).

CONCLUSION

LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.

An investigational study of a dual-layer, chorion-free amnion patch as a protective barrier following lumbar laminectomy in a sheep model

The inherent properties of the human amniotic membrane (HAM) suggest its potential for use as a physical barrier during surgery to protect neural elements and vessels from the surrounding environment. The objective of this study was to evaluate the effect of a dual-layer, chorion-free amnion patch (DLAM; ViaShield®, Globus Medical Inc., Audubon, PA, USA) processed from HAM as a protective barrier following lumbar laminectomy in a sheep model. A multiplex immunoassay was performed to quantify the inherent cytokines present in the amnion after processing. Twelve skeletally mature female crossbred Suffolk sheep were randomly divided into two equal post-operative periods (4 and 10 weeks). Each sheep underwent a laminectomy at L3 and L5, and one of the surgical sites randomly received the DLAM treatment. At each postsurgical time point, the extent of epidural fibrosis and neurohistopathological responses at the laminectomy sites was assessed based on epidural fibrosis-dura tenacity scores and decalcified histology, respectively. Immunoassay results showed that inflammatory mediators and immunomodulatory cytokines were present in the amnion after processing, but no proangiogenic cytokines were detected. At 10 weeks, tissue tenacity was significantly less in the DLAM treatment group when compared with the operative control (1.2 ± 0.4 vs. 2.8 ± 0.4, p < 0.05), demonstrating the ability of DLAM to act as a barrier and cover the dura. Gross observations showed fewer fibroblasts in the DLAM group in comparison with the control at both post-operative time points. Fibroblast infiltration analysis indicated that at both 4 and 10 weeks, there were significantly more infiltrated fibroblasts in the operative control sites than in the DLAM-treated sites, expressed as a percentage of the total number of fibroblasts present (4 weeks: 72.3 ± 10.2% vs. 10.8 ± 10.1%, p < .05; 10 weeks: 84.9 ± 15.8% vs. 43.1 ± 11.6%, p < .05). Additionally, fibroblasts travelled further into the dura in the operative control group compared with the DLAM-treated group at both time points. In conclusion, this study found that DLAM reduced fibroblast infiltration and tissue tenacity following lumbar laminectomy in a sheep animal model. These findings support the potential use of DLAM in clinical practice as a protective barrier for neural elements and anterior vessels.

The biomechanical effect of single-level laminectomy and posterior instrumentation on spinal stability in degenerative lumbar scoliosis: a human cadaveric study

OBJECTIVEDegenerative lumbar scoliosis, or de novo degenerative lumbar scoliosis, can result in spinal canal stenosis, which is often accompanied by disabling symptoms. When surgically treated, a single-level laminectomy is performed and short-segment posterior instrumentation is placed to restore stability. However, the effects of laminectomy on spinal stability and the necessity of placing posterior instrumentation are unknown. Therefore, the aim of this study was to assess the stability of lumbar spines with degenerative scoliosis, characterized by the range of motion (ROM) and neutral zone (NZ) stiffness, after laminectomy and placement of posterior instrumentation.METHODSTen lumbar cadaveric spines (T12-L5) with a Cobb angle ≥ 10° and an apex on L3 were included. Three loading cycles were applied per direction, from -4 Nm to 4 Nm in flexion/extension (FE), lateral bending (LB), and axial rotation (AR). Biomechanical evaluation was performed on the native spines and after subsequent L3 laminectomy and the placement of posterior L2-4 titanium rods and pedicle screws. Nonparametric and parametric tests were used to analyze the effects of laminectomy and posterior instrumentation on NZ stiffness and ROM, respectively, both on an individual segment's motion and on the entire spine section. Spearman's rank correlation coefficient was used to study the correlation between disc degeneration and spinal stability.RESULTSThe laminectomy increased ROM by 9.5% in FE (p = 0.04) and 4.6% in LB (p = 0.01). For NZ stiffness, the laminectomy produced no significant effects. Posterior instrumentation resulted in a decrease in ROM in all loading directions (-22.2%, -24.4%, and -17.6% for FE, LB, and AR, respectively; all p < 0.05) and an increase in NZ stiffness (+44.7%, +51.7%, and +35.2% for FE, LB, and AR, respectively; all p < 0.05). The same changes were seen in the individual segments around the apex, while the adjacent, untreated segments were mostly unaffected. Intervertebral disc degeneration was found to be positively correlated to decreased ROM and increased NZ stiffness.CONCLUSIONSLaminectomy in lumbar spines with degenerative scoliosis did not result in severe spinal instability, whereas posterior instrumentation resulted in a rigid construct. Also, prior to surgery, the spines already had lower ROM and higher NZ stiffness in comparison to values shown in earlier studies on nonscoliotic spines of the same age. Hence, the authors question the clinical need for posterior instrumentation to avoid instability.

Decompression of lumbar canal stenosis with a bilateral interlaminar versus classic laminectomy technique: a prospective randomized study

OBJECTIVEThe aim of this study was to compare the radiological and clinical results of bilateral interlaminar canal decompression and classic laminectomy in lumbar canal stenosis (LCS).METHODSTwo hundred eighteen patients with LCS were randomized to surgical treatment with classic laminectomy (group 1) or bilateral interlaminar canal decompression (group 2). Low-back and leg pain were evaluated according to the visual analog scale (VAS) both preoperatively and postoperatively. Disability was evaluated according to the Oswestry Disability Index (ODI) preoperatively and at 1 month, 1 year, and 3 years postoperatively. Neurogenic claudication was evaluated using the Zurich Claudication Questionnaire (ZCQ) preoperatively and 1 year postoperatively. The two treatment groups were compared in terms of neurogenic claudication, estimated blood loss (EBL), and intra- and postoperative complications.RESULTSPostoperative low-back and leg pain declined as compared to the preoperative pain. Both groups had significant improvement in VAS, ODI, and ZCQ scores, and the improvements in ODI and back pain VAS scores were significantly better in group 2. The average EBL was 140 ml in group 2 compared to 260 ml in group 1. Nine patients in the laminectomy group developed postoperative instability requiring fusion compared to only 4 cases in the interlaminar group (p = 0.15). Complications frequency did not show any statistical significance between the two groups.CONCLUSIONSBilateral interlaminar decompression is an effective method that provides sufficient canal decompression with decreased instability in cases of LCS and increases patient comfort in the postoperative period.

Restoration of the Spinous Process Following Muscle-Preserving Posterior Lumbar Decompression via Sagittal Splitting of the Spinous Process

Background

In lumbar spinal stenosis, spinous process-splitting decompression has demonstrated good clinical outcomes with preservation of the posterior ligamentous complex and paraspinal muscles in comparison to conventional laminectomy, but the radiological consequence and clinical impact of the split spinous processes have not been fully understood.

Methods

Seventy-three patients who underwent spinous process-splitting decompression were included. The bone union rate and pattern were evaluated by computed tomography performed 6–18 months after surgery and compared among subgroups divided according to the number of levels decompressed and the extent of spinous process splitting. The bone union pattern was classified into three categories: complete union, partial union, and nonunion. The visual analog scale (VAS) score, Oswestry disability index (ODI), and walking distance assessed both before and 24–36 months after surgery were compared among subgroups divided according to the union pattern of the split spinous process.

Results

Overall, the rates of complete union, partial union, and nonunion were 51.7%, 43.2%, and 5.1%, respectively. In the subgroup with partial splitting of the spinous process, the rates were 85.7%, 14.3%, and 0%, respectively; those of the subgroup with total splitting of the spinous process were 32.9%, 59.2%, and 7.9%, respectively. With single-level decompression, a higher rate of union was observed compared with multilevel decompression. The VAS, ODI, and walking distance were significantly improved after surgery and did not differ according to the degree of union of the split spinous process.

Conclusions

We found that the single-level operation and partial splitting of the spinous process were favourable factors for obtaining complete restoration of the posterior bony structure of the lumbar spine in spinous process-splitting decompression.

Bone-Preserving Decompression Procedures Have a Minor Effect on the Flexibility of the Lumbar Spine

Objective

To mitigate the risk of iatrogenic instability, new posterior decompression techniques able to preserve musculoskeletal structures have been introduced but never extensively investigated from a biomechanical point of view. This study was aimed to investigate the impact on spinal flexibility caused by a unilateral laminotomy for bilateral decompression, in comparison to the intact condition and a laminectomy with preservation of a bony bridge at the vertebral arch. Secondary aims were to investigate the biomechanical effects of two-level decompression and the quantification of the restoration of stability after posterior fixation.

Methods

A universal spine tester was used to measure the flexibility of six L2–L5 human spine specimens in intact conditions and after decompression and fixation surgeries. An incremental damage protocol was applied : 1) unilateral laminotomy for bilateral decompression at L3–L4; 2) on three specimens, the unilateral laminotomy was extended to L4–L5; 3) laminectomy with preservation of a bony bridge at the vertebral arch (at L3–L4 in the first three specimens and at L4–L5 in the rest); and 4) pedicle screw fixation at the involved levels.

Results

Unilateral laminotomy for bilateral decompression had a minor influence on the lumbar flexibility. In flexion-extension, the median range of motion increased by 8%. The bone-preserving laminectomy did not cause major changes in spinal flexibility. Two-level decompression approximately induced a twofold destabilization compared to the single-level treatment, with greater effect on the lower level. Posterior fixation reduced the flexibility to values lower than in the intact conditions in all cases.

Conclusion

In vitro testing of human lumbar specimens revealed that unilateral laminotomy for bilateral decompression and bone-preserving laminectomy induced a minor destabilization at the operated level. In absence of other pathological factors (e.g., clinical instability, spondylolisthesis), both techniques appear to be safe from a biomechanical point of view.

Trends in Lumbar Fusion Surgery Among Octogenarians: A Nationwide Inpatient Sample Study From 2004 to 2013

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

Given the aging US population and natural degenerative process of the spine, more elderly patients with lumbar spinal disease are surgical candidates. Prior studies have assessed safety and efficacy of lumbar fusion (LF) surgeries in the elderly, but none have reviewed fusion procedures from an epidemiological standpoint. Here, we report 2004-2013 national trends in demographics, discharge time, and economic impact of LF procedures for octogenarians.

METHODS

The Nationwide Inpatient Sample database was queried from 2004 to 2013 for LF procedures in patients aged 80 to 89 years. Patients were grouped by fusion level, demographics, comorbidity score, insurance, and hospital characteristics. Postoperative variables include length of stay and total in-hospital charges. Data was evaluated using chi-squared tests and t tests.

RESULTS

The national sample included 17 471 LF procedures (mean age = 82.65 years). From 2004 to 2013, the annual number of LF procedures increased from 1144 to 2061 patients. Percentage of multilevel LF was relatively maintained (mean = 18%). The majority of patients were female (mean = 62%). The proportion of males increased during the study period (31.8% to 42.5%; P < .0001). The proportion of patients with a comorbidity score of 2 or 3 increased during the study period (P < .0001). Over time, average length of stay decreased (from 6 to 4.5 days; P < .0001), and total in-hospital charges increased (from $58 471 to $111 235; P < .0001).

CONCLUSIONS

These results suggest that more lumbar fusion procedures are being performed on octogenarians in recent years. While these patients are discharged from hospitals more quickly after surgery, there is also greater financial burden placed on patients, hospitals, and society.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery

BACKGROUND

Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear.

METHODS

The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable.

RESULTS

Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93).

CONCLUSIONS

Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

Outcome after Surgery of Lumbar Spinal Stenosis: A Randomized Comparison of Bilateral Laminotomy, Trumpet Laminectomy, and Conventional Laminectomy

Background

Laminectomy is the traditional operating method for the decompression of spinal canal stenosis. New partial decompression processes have been suggested in the treatment of lumbar stenosis. The benefit of a micro surgical approach is the chance of an extensive bilateral decompression of the spinal canal or foramen at one or numerous levels, through a minimal para-spinal muscular separation.

Purpose

To match the safety and the clinical consequences after a bilateral laminotomy, laminectomy and trumpet laminectomy in patients with lumbar spinal stenosis who were randomized to one of three treatment groups.

Study design

Prospective study.

Methods

One hundred twenty consecutive patients with 227 levels of lumbar stenosis without significant herniated discs or instability were randomized to three treatment groups [bilateral laminotomy (Group 1), laminectomy (Group 2), and trumpet laminectomy (Group 3)]. Perioperative parameters and complications were documented. Symptoms and scores, such as a visual analog scale (VAS), Oswestry Disability Index, and patient satisfaction, were assessed preoperatively at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients on the basis of surgeon satisfaction.

Results

The global complication rate was lowest in patients who had undertaken bilateral laminotomy (Group 1). The minimum follow-up of 12 months was achieved in 100% of patients. Matched with that experience in Group 1, but, with more remaining back and leg pain was found in Group 2, 3.85 ± 0.28 and 1.60 ± 0.44, respectively and 3.24 ± 0.22 and 2.44 ± 0.26 in Group 3, respectively compared with 1.84 ± 0.28 and 1.25 ± 0.12 (Group 1) at the 1-year follow-up assessment (p < 0.05). It was the same for the ODI scores, which reached 14 ± 8% (Group 1), 28 ± 12% (Group 2), and 26 ± 16 after 12 months of surgery (Group 3) (significant, p < 0.01 compared with preoperative scores). Patient satisfaction was higher in Group 1, with 7.5, 20, and 25% of patients displeased (in Groups 1, 2, and 3, respectively; p < 0.01).

Conclusion

Bilateral Laminotomy is certified acceptable and harmless in decompression of lumbar stenosis, causing a highly significant decrease of symptoms and disability.

Morbidity and mortality of complex spine surgery: a prospective cohort study in 679 patients validating the Spine AdVerse Event Severity (SAVES) system in a European population

BACKGROUND CONTEXT

Most literature on complications in spine surgery has been retrospective or based on national databases with few variables. The Spine AdVerse Events Severity (SAVES) system has been found reliable and valid in two Canadian centers, providing precise information regarding all adverse events (AEs).

PURPOSE

This study aimed to determine the mortality and examine the incidence of morbidity in patients undergoing complex spinal surgery, including pediatric patients, and to validate the SAVES system in a European population.

STUDY DESIGN

A prospective, consecutive cohort study was conducted using the SAVES version 2010 in the period from January 1, 2013 until December 31, 2013. A retrospective analysis was performed on all patients operated from November 1, 2011 until October 31, 2012 for comparison.

PATIENT SAMPLE

Patients undergoing spinal surgery at a tertiary referral center comprised the patient sample.

OUTCOME MEASURES

Morbidity and mortality were determined according to the newest version of the SAVES system and compared with the Canadian cohort. Other outcomes were length of stay, readmission, unplanned second surgery during index admission, as well as wound infections requiring revision.

METHODS

All patients undergoing spinal surgery at an academic tertiary referral center in the study period were prospectively included. The newest version of SAVES system was used, and a research coordinator collected all intraoperative and perioperative data prospectively. Once a week all patients were reviewed for additional events, validation of the data, and clarification of any questions. Patients were grouped according to the type of admission (elective of emergency) and age, and subgrouped according to a major diagnostic group. The survival status was registered on January 31, 2014 to obtain 30-day survival.

RESULTS

A total of 679 consecutive cases were included with 100% data completion. The in-hospital mortality was 1.3% and the 30-day mortality was 2.7%; all occurring after emergency procedures. The number of intraoperative AEs was 162 (overall incidence 20%), and the number of postoperative AEs was 1,415 (overall incidence 77%). Of the patients, 2.2% had postoperative infections requiring surgical revision.

CONCLUSIONS

A prospective registration improves AE recognition, and our data confirm the generalizability of the SAVES system to pediatric and non-Canadian populations.

Minimally invasive spine surgery for adult degenerative lumbar scoliosis

OBJECT

Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.

METHODS

In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.

RESULTS

Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).

CONCLUSIONS

The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

Spinal decompression in achondroplastic patients using high-speed drill versus ultrasonic bone curette: technical note and outcomes in 30 cases

BACKGROUND

This manuscript describes the clinical and operative characteristics of achondroplastic children who undergo multilevel thoracolumbar decompressions using either the high-speed drill or the ultrasonic bone curette (BoneScalpel).

METHODS

We retrospectively reviewed 30 thoracolumbar decompressions in achondroplastic patients at a single institution between 2008 and 2013. Patients were classified into either the high-speed drill cohort or the BoneScalpel cohort, depending on which instrument was utilized to perform the decompression. A technical note on the role of the ultrasonic bone curette in decompressing stenotic achondroplastic spines is also provided.

RESULTS

In comparison with the high-speed drill cohort, the BoneScalpel cohort experienced less overall perioperative complications, including durotomy, cerebrospinal fluid leak, pseudomeningoceles, wound infection, and wound dehiscence. Although 45.0% of patients experienced a durotomy in the high-speed drill cohort, only 30.0% of patients experienced a durotomy in the BoneScalpel cohort (P = 0.694). In the high-speed drill cohort, the number of patients complaining of sensory disturbances, back pain, ataxia, incontinence, neurogenic claudication, radiculopathy, ataxia, and/or weakness decreased postoperatively. Similar results were observed in the BoneScalpel cohort.

CONCLUSIONS

Although spinal decompression provides symptomatic resolution in patients with achondroplasia, intraoperative complications, in general, and durotomies, in particular, are common. Here, we report a decreased incidence in intraoperative durotomy and overall perioperative complication rates in the BoneScalpel cohort, although this did not reach the level of statistical significance. Nonetheless, the data demonstrate that the BoneScalpel is a safe and efficacious alternative to the high-speed drill in these challenging patients.

LEVEL OF EVIDENCE

Level II-retrospective study.

Lumbar spinal stenosis: therapeutic options review

Lumbar spinal stenosis (LSS) functionally impacts significant numbers of Americans per year. Current estimates place the number of Americans suffering from senescent lumbar spinal stenosis at 400,000. The prevalence of this disorder in patients ranging from 60 to 69 years of age is very high. Forty-seven percent of this age group have mild to moderate stenosis, and 19.7% have severe stenosis. As the baby boomer generation gets older, 10,000 individuals attain the age of 65 years every day in United States. LSS is becoming very common and will be a major healthcare issue as the population ages. Although LSS is not life threatening, it can cause substantial disability with limitations to performing daily activities, and thus, the associated negative impact on quality of life (QOL). This article reviews the pathophysiology and current treatment options for LSS, focusing on evidence-based treatment options.

Long-term clinical and radiological postoperative outcomes after an interspinous microdecompression of degenerative lumbar spinal stenosis

STUDY DESIGN

A retrospective study to evaluate the clinical outcome and the risk of postoperative instability 5 years after microsurgical management of lumbar spinal stenosis using the interspinous approach.

OBJECTIVE

To evaluate the long-term outcome and the risk of postoperative instability after the microsurgical interspinous decompression of lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

The interspinous approach involves partial resection of the supraspinous ligament followed by resection of the interspinous ligament, partial resection of the caudal aspect of the superior spinous process and resection of the ligamentum flavum, producing a central fenestration through which the decompression of the cauda equina and the nerve roots can be effected with an undercutting technique, with tailored partial resection of the lamina and the medial aspects of the facet joints. In this article, we investigated the long-term clinical outcome and the long-term risk for instability after using this approach.

METHODS

One hundred and 6 patients undergoing decompressive surgery for lumbar spinal stenosis using the interspinous approach, including cases with spondylolisthesis without instability, were included in this study. The long-term outcome was evaluated in a follow-up study, 5 years after surgery. The clinical long-term outcome was evaluated retrospectively using self-rating questionnaires: the Oswestry Disability Index, visual analogue scale (0-10), walking capacity (1-5), progress in walking capacity and global activity, and level of satisfaction. The risk of postoperative instability was evaluated on the basis of dynamic radiographs of the lumbar spine.

RESULTS

The Oswestry Disability Index showed a mean improvement in symptoms from 58.20% to 21.61%, and the visual analogue scale showed that the intensity of leg and back pain decreased from 8.62 and 8.69 points to 2.33 and 3.48 points, respectively. Walking capacity increased from 3.37 (severely restricted) to 1.81 (slightly restricted), and 93.23% of cases indicated that they were moderately satisfied or very satisfied. Dynamic radiographs revealed no postoperative instability after decompression using the interspinous approach.

CONCLUSION

The clinical outcome 5 years postoperatively after using the interspinous approach for lumbar spinal stenosis showed a favorable maintenance of improvement in symptoms. Radiological data showed that this approach does not alter the stability of the spine.

LEVEL OF EVIDENCE

4.

The efficacy and perioperative complications associated with lumbar spinal fusion surgery, focusing on geriatric patients in the republic of Korea

Objective

The purpose of this study was to examine the efficacy and perioperative complications associated with lumbar spinal fusion surgery, focusing on geriatric patients in the Republic of Korea.

Methods

We retrospectively investigated 485 patients with degenerative spinal diseases who had lumbar spinal fusion surgeries between March 2006 and December 2010 at our institution. Age, sex, comorbidity, American Society of Anesthesiologists (ASA) class, fusion segments, perioperative complications, and outcomes were analyzed in this study. Risk factors for complications and their association with age were analyzed.

Results

In this study, 81 patients presented complications (16.7%). The rate of perioperative complications was significantly higher in patients 70 years or older than in other age groups (univariate analysis, p=0.015; multivariate analysis, p=0.024). The perioperative complications were not significantly associated with the other factors tested (sex, comorbidity, ASA class, and fusion segments). Post-operative outcomes of lumbar spinal fusion surgeries for the patients were determined on the basis of MacNab's criteria (average follow up period : 19.7 months), and 412 patients (85.0%) were classified as having "excellent" or "good" results.

Conclusion

Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery, whereas other factors were not significant. However, patients' satisfaction or return to daily activities when compared with younger patients did not show much difference. We recommend good clinical judgment as well as careful selection of geriatric patients for lumbar spinal fusion surgery.

Readmission rates after decompression surgery in patients with lumbar spinal stenosis among Medicare beneficiaries

STUDY DESIGN

Retrospective observational cohort analysis of administrative claims.

OBJECTIVE

Estimate readmission rates after spine stenosis decompression surgery in a 5% randomly selected sample of Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Operative management of lumbar spinal stenosis has significant and measurable benefits compared with nonoperative care. Revision rates for lumbar decompression with and without fusion have been reported with significant variability. An understanding of readmission and reoperation rates informs decisions regarding the cost-effective management of lumbar stenosis.

METHODS

Patients were identified in 2005-2009 Medicare claims who had both a procedure code for decompression (03.09), and a diagnosis of lumbar spinal stenosis (724.02). Patients diagnosed with spondylolisthesis, and those receiving revision surgery or fusion of more than 3 segments were excluded. Kaplan-Meier product limit method was used to estimate univariate rates of readmission for fusion, decompression, or injection and Cox proportional hazards to examine whether fusion decreased the likelihood of readmission.

RESULTS

The overall 1-year readmission rate was slightly higher in patients undergoing fusion with decompression (9.7%) than patients who underwent decompression alone (7.2%, P = 0.03). Rates at 2 years were 14.6% and 12.5%, respectively. Patients receiving decompression with fusion were slightly younger and more likely female. Procedures performed during readmission were similar for the fusion and no fusion cohorts with 56% receiving fusion, 23% decompression, and 22% injection for pain management. Of the patients who were not readmitted, more than 25% of patients received outpatient injections for pain management during the 3-month quarter of their surgery and approximately 20% in the subsequent quarter.

CONCLUSION

Readmission rates for spinal stenosis decompression were approximately 8% to 10% per year. Fusion at the index procedure did not protect against subsequent readmission. Large databases can inform choice of surgical options by focusing examination on indications for surgery and reasons for readmission. Fusion along with decompression does not seem to impact readmission rates.

Descompressão e instrumentação na estenose lombar: relação entre os níveis operados e as complicações intra e pós-operatórias imediatas

OBJECTIVO: Na cirurgia lombar, a instrumentação pedicular proporciona a estabilização dos segmentos afectados e favorece a artrodese. Trata-se na maioria das vezes de procedimentos complexos em pacientes idosos e com várias co-morbilidades. O número de níveis a descomprimir/artrodesar nem sempre é consensual. Os autores pretendem determinar se existe relação entre o número de níveis operados e as complicações intra e pós-operatórias. MÉTODOS: Estudo retrospectivo que incluiu 50 indivíduos com estenose lombar submetidos a descompressão e fixação vertebral posterior entre 2009 e 2010. Idade média 65,98±8,82 anos. Contabilização dos níveis instrumentados (NI) e níveis descomprimidos (ND). Variáveis averiguadas: Tempo de recobro em unidade pós-anestésica/intensivos (UPA); Unidades de glóbulos rubros transfundidos (GR); Variação da concentração de Hemoglobina (Hgb); Tempo cirúrgico (minutos); dias de internamento; ASA score (American Society of Anesthesiologists). Contabilização das complicações neurológicas, infecciosas, vasculares, Mau posicionamento parafusos e doentes reoperados. Divisão em dois grupos: Grupo A: ≤3 NI e GrupoB: >3 NI. Estudo estatístico em SPSS®. RESULTADOS: Relação entre NI e ND com mais GR, mais tempo UPA, maior perda Hgb e maior tempo cirúrgico (p<0,05). Relação entre NI e ND com maior número de complicações (p<0,05). Instrumentações/descompressões >3 níveis associadas a maior necessidade de transfusão (p<0,05), mais tempo na UPA (p<0,05), maior perda hemática (p<0,05), maior tempo cirúrgico (p<0,05) e maior incidência de complicações (p<0,05). CONCLUSÃO: Na estenose lombar, instrumentações/descompressões acima de três níveis têm taxa de complicações mais elevada, assim, no planeamento pré-operatório a relação risco/benefício deve ser ponderada particularmente nos pacientes mais idosos e com mais co-morbilidades.

Complications in lumbar spine surgery: A retrospective analysis

BACKGROUND

Surgical treatment of adult lumbar spinal disorders is associated with a substantial risk of intraoperative and perioperative complications. There is no clearly defined medical literature on complication in lumbar spine surgery. Purpose of the study is to retrospectively evaluate intraoperative and perioperative complications who underwent various lumbar surgical procedures and to study the possible predisposing role of advanced age in increasing this rate.

MATERIALS AND METHODS

From 2007 to 2011 the number and type of complications were recorded and both univariate, (considering the patients' age) and a multivariate statistical analysis was conducted in order to establish a possible predisposing role. 133 were lumbar disc hernia treated with microdiscetomy, 88 were lumbar stenosis, treated in 36 cases with only decompression, 52 with decompression and instrumentation with a maximum of 2 levels. 26 patients showed a lumbar fracture treated with percutaneous or open screw fixation. 12 showed a scoliotic or kyphotic deformity treated with decompression, fusion and osteotomies with a maximum of 7.3 levels of fusion (range 5-14). 70 were spondylolisthesis treated with 1 or more level of fusion. In 34 cases a fusion till S1 was performed.

RESULTS

Of the 338 patients who underwent surgery, 55 showed one or more complications. Type of surgical treatment (P = 0.004), open surgical approach (open P = 0.001) and operative time (P = 0.001) increased the relative risk (RR) of complication occurrence of 2.3, 3.8 and 5.1 respectively. Major complications are more often seen in complex surgical treatment for severe deformities, in revision surgery and in anterior approaches with an occurrence of 58.3%. Age greater than 65 years, despite an increased RR of perioperative complications (1.5), does not represent a predisposing risk factor to complications (P = 0.006).

CONCLUSION

Surgical decision-making and exclusion of patients is not justified only by due to age. A systematic preoperative evaluation should always be performed in order to stratify risks and to guide decision-making for obtaining the best possible clinical results at lower risk, even for elderly patients.

Incidental durotomy after spinal surgery: a prospective study in an academic institution

Object

Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes.

Methods

The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID.

Results

Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%).

Conclusions

The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.

Morbidity and mortality after spinal deformity surgery in patients 75 years and older: complications and predictive factors

Object

As the population continues to age, relatively older geriatric patients will present more frequently with complex spinal deformities that may require surgical intervention. To the authors' knowledge, no study has analyzed factors predictive of complications after major spinal deformity surgery in the very elderly (75 years and older). The authors' objective was to determine the rate of minor and major complications and predictive factors in patients 75 years of age and older who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure.

Methods

Twenty-one patients who were 75 years of age or older and underwent thoracic and/or lumbar fixation and arthrodesis across 5 or more levels for spinal deformity were analyzed retrospectively. The medical and surgical records were reviewed in detail. Age, diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Factors predictive of perioperative complications were identified by logistic regression analysis.

Results

The mean patient age was 77 years old (range 75–83 years). There were 14 women and 7 men. The mean follow-up was 41.2 months (range 24–81 months). Fifteen patients (71%) had at least 1 comorbidity. A mean of 10.5 levels were fused (range 5–15 levels). Thirteen patients (62%) had at least 1 perioperative complication, and 8 (38%) had at least one major complication for a total of 17 complications. There were no perioperative deaths. Increasing age was predictive of any perioperative complication (p = 0.03). However, major complications were not predicted by age or comorbidities as a whole. In a subset analysis of comorbidities, only hypertension was predictive of a major complication (OR 10, 95% CI 1.3–78; p = 0.02). Long-term postoperative complications occurred in 11 patients (52%), and revision fusion surgery was necessary in 3 (14%).

Conclusions

Patients 75 years and older undergoing major spinal deformity surgery have an overall perioperative complication rate of 62%, with older age increasing the likelihood of a complication, and a long-term postoperative complication rate of 52%. Patients in this age group with a history of hypertension are 10 times more likely to incur a major perioperative complication. However, the mortality risk for these patients is not increased.

Predictors of surgical, general and follow-up complications in lumbar spinal stenosis relative to patient age as emerged from the Spine Tango Registry

INTRODUCTION

Published opinions regarding the outcomes and complications in older patients have a broad spectrum and there is a disagreement whether surgery in older patients entails a higher risk. Therefore this study examines the risk of surgery for lumbar spinal stenosis relative to age in the pooled data set of the Spine Tango registry.

MATERIALS AND METHODS

Between May 2005 and February 2010 the database query resulted in 1,764 patients. The patients were subdivided into three socio-economically relevant age groups: <65 years, 65-74 years, ≥75 years. Frequencies for occurred surgical, general and follow-up complications were assessed. Multivariate and univariate logistic regressions were performed to reveal predictors for respective complication types.

RESULTS AND DISCUSSION

Our study found that age, ASA status and blood loss were significant co-varieties for the occurrence of general complications. The risk of general complications is increased in older versus younger patients. Fusion or rigid stabilization does not lead to more complications. Surgical complications as well as complication rates at follow-up showed no significant age-related variation. Physician-based outcome was good or excellent in over 80% of patients in all age groups.

Lumbar fusion in octogenarians: the promise of minimally invasive surgery

STUDY DESIGN

Retrospective chart review of prospectively collected data from 2 nonrandomized, nonconcurrent cohorts.

OBJECTIVE

Early results of 2 lumbar interbody fusion procedures-open posterior lumbar interbody fusion (PLIF) and minimally invasive (extreme lateral interbody fusion [XLIF])-were compared in octogenarians to demonstrate the safety of each in the extreme elderly populations.

SUMMARY OF BACKGROUND DATA

Although spinal pathologies are common in the elderly patients, additional health conditions often preclude operative treatment because anesthesia, blood loss, and recovery are too demanding. Minimally invasive approaches reduce procedure-related morbidity and recovery time.

METHODS

In our single-site prospective series of XLIF patients, 40 were identified as those aged ≥80 years with a minimum of 3-month follow-up. A complete, retrospective review of surgical patients treated in the same practice with traditional open posterior (PLIF) approach found 20 patients aged ≥80 years. Comparisons were made between groups to identify differences in morbidity and mortality rates.

RESULTS

No clinically significant differences in demographics, diagnoses, or comorbidities were found between groups. Complication rate, blood loss/transfusion rate, and hospital stay were significantly lower in the minimally invasive surgery (MIS) group (P < 0.0001). MIS patients left the hospital an average of 4 days earlier than the open PLIF patients, most discharged home (92.5% XLIF vs. 0% PLIF) rather than to skilled nursing facilities. Six deaths occurred in the PLIF follow-up, 3 within 3 months postoperatively; there was 1 death at 6 months postoperatively XLIF.

CONCLUSION

Surgical treatment need not be withheld on the basis of age; elderly patients can successfully be treated using MIS techniques, and are-in our experience-among the most satisfied with their outcomes, enjoying significant improvements in pain, mobility, and quality of life.

The analysis of the factors affecting lumbar spinal stenosis in adult patients

BACKGROUND

In this study 67 lumbar spinal stenosis in adult patients operated in our clinic in 3 years are aimed to be analysed in terms of clinical and surgical techniques.

METHODS

Diagnoses were made on the basis of patients' histories and their clinical examinations.

RESULTS

Average age was 52.16 +/- 8.9 (33-64). 70.1% (47) of patients were females and 29.9% (20) were males. The most frequent neurological symptoms were 71.1% lasque (+) and 56.7% sensory loss. The anterior-posterior diameter was below 11.5 mm in 56.7% of the cases. Partial recovery was observed in the early term of 71.6% the cases. 56.7% of the cases were applied total laminectomy.

CONCLUSION

Decompressive laminectomy can be performed safely and effectively in patients of with lumbar stenosis.

Survivorship of coflex Interlaminar-Interspinous Implant

BACKGROUND

The purpose of this study was to determine the indications for implantation of the coflex device (Paradigm Spine, LLC, New York, New York), assess long-term complications, and evaluate the long-term clinical outcomes of patients.

METHODS

A total of 127 patients underwent placement of a coflex implant for various indications by one orthopaedic spine surgeon. The mean follow-up was 6.3 years. The original indications for implantation were determined based upon the data provided in the case report forms. Preoperatively and postoperatively, patients were asked to grade their low-back and leg pain using the visual analog scale (VAS) and the pain severity scale: no pain (0), mild pain (1), moderate pain (2), or severe pain (3). Patients were queried about their satisfaction with the surgical procedure. Follow-up radiographs were taken to determine any device-related issues.

RESULTS

The most prevalent diagnoses for implantation were spinal stenosis (19.7%) and spinal stenosis with lumbar disc herniation (35.4%). The mean severity of low-back pain was decreased by 33% (from moderate to mild) at the 2-year follow-up (P < .001) and at the 5-year follow-up (from moderate to mild, P < .001). The mean severity of leg pain was decreased by 66% (from severe to mild) at the 2-year follow-up (P < .001) and at the 5-year follow-up (from severe to mild, P < .001). At the mean follow-up period of 6.3 years, a patient satisfaction query demonstrated that 7% were unsatisfied, 46% were satisfied, and 46% were very satisfied with their clinical outcome. Based on the follow-up radiographs, 92 of patients had no devicerelated issues and 8% had device-related issues.

CONCLUSION

The data provided have demonstrated that the coflex implant provides pain relief for patients with low-back pain and leg pain. The most common indications for implantation were spinal stenosis and spinal stenosis with lumbar disc herniation. There were very few device-related complications.

CLINICAL SIGNIFICANCE

Using coflex is a safe and viable option in the selection of instrumentation for spinal stabilization.

Rates of perioperative complications associated with laminectomies in patients with achondroplasia

BACKGROUND

Lumbar decompressive surgery can be complicated by dural tears, infection, nerve root injury, deep venous thrombosis, and epidural hematoma. However, perioperative complications of multilevel laminectomies in patients with achondroplasia rarely are reported. Our objective was to determine the perioperative complication rates associated with laminectomies in patients with achondroplasia.

METHODS

We reviewed the medical records of the initial laminectomies for all ninety-eight patients with achondroplasia at our institution, which included twenty-eight patients who had had previous spine surgeries at other institutions, and determined the rates of complications in the following categories: neurologic, pulmonary, cardiovascular, and gastrointestinal complications; intraoperative dural tears; infections at the incision site; and mortality.

RESULTS

Sixty (61%) of ninety-eight patients had at least one perioperative complication. By category, these included intraoperative dural tears, which occurred in 37% (thirty-six patients); neurologic complications, in 23% (twenty-three patients); infections at the incision site, in 9% (nine patients); deep venous thrombosis, in 3% (three patients); pulmonary complications, in 3% (three patients); and gastrointestinal complications, in 3% (three patients). The only death was caused by a pulmonary embolism.

CONCLUSIONS

Perioperative complications are common in patients with achondroplasia undergoing multilevel laminectomies, and the perioperative care team should be aware of these complications when caring for these patients.

Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians

The purpose of our prospective study is to evaluate the surgical outcome among patients aged 80 years and above, who underwent surgery for lumbar spinal stenosis. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. Thirty-nine patients more than 80 years of age were operated in our institution in the last decade. Twenty-five of them were followed-up with a mean 36.8 months after the operation. The Barthel index was used to evaluate pre and postsurgery ADL, and the visual analogue scale (VAS) was used to evaluate pain. The satisfaction rate of the patients before and after the operation and the complication rate were also evaluated. A significant reduction in VAS (P < 0.001) and a significant increase in the Barthel index (P < 0.001) were recorded. Seventy-six percent of the patients were very satisfied or somewhat satisfied with the operative results. Fifty-two percent of the patients had complications (0.9 complications per patients), however, about half of them were minor. No operative or perioperative mortality was noticed and the overall hospital stay for these elderly patients was 3.6 days on average. Surgery in very old elderly patients is safe and effective in the treatment of spinal stenosis, who did not respond well to the conservative treatment. The surgery did not increase the associated morbidity and mortality and most of the patients benefited from the surgery in terms of reduction in pain, increase in ADL and walking ability and overall increase in the satisfaction rate.