Tag: Lumbar

Posted on

Low-back pain after lumbar discectomy for disc herniation: what can you tell your patient?

J Neurosurg Spine 35:715–721, 2021

Lumbar discectomy (LD) is frequently performed to alleviate radicular pain resulting from disc herniation. While this goal is achieved in most patients, improvement in low-back pain (LBP) has been reported inconsistently. The goal of this study was to characterize how LBP evolves following discectomy.

METHODS The authors performed a retrospective analysis of prospectively collected patient data from the Canadian Spine Outcomes and Research Network (CSORN) registry. Patients who underwent surgery for lumbar disc herniation were eligible for inclusion. The primary outcome was a clinically significant reduction in the back pain numerical rating scale (BPNRS) assessed at 12 months. Binary logistic regression was used to model the relationship between the primary outcome and potential predictors.

RESULTS There were 557 patients included in the analysis. The chief complaint was radiculopathy in 85%; 55% of patients underwent a minimally invasive procedure. BPNRS improved at 3 months by 48% and this improvement was sustained at all follow-ups. LBP and leg pain improvement were correlated. Clinically significant improvement in BPNRS at 12 months was reported by 64% of patients. Six factors predicted a lack of LBP improvement: female sex, low education level, marriage, not working, low expectations with regard to LBP improvement, and a low BPNRS preoperatively.

CONCLUSIONS Clinically significant improvement in LBP is observed in the majority of patients after LD. These data should be used to better counsel patients and provide accurate expectations about back pain improvement.

Posted on

Modified far lateral endoscopic transforaminal lumbar interbody fusion using a biportal endoscopic approach

Acta Neurochirurgica (2021) 163:1205–1209

Endoscopic transforaminal lumbar interbody fusion (TLIF) has the disadvantage of the small cage size and by consequence risk for cage subsidence. We succeeded to insert a large oblique lumbar interbody fusion (OLIF) cage during biportal endoscopic TLIF.

Methods Unilateral total facetectomy was performed to expose the exiting and traversing nerve roots. The distance between the exiting and traversing nerve roots was measured before OLIF cage insertion. We inserted an OLIF cage instead of a TLIF cage.

Conclusion We successfully performed modified far lateral biportal endoscopic TLIF using large OLIF cages. Modified far lateral biportal endoscopic TLIF is usually suitable for the L4-5 and L5-S1 levels.

Posted on

Predictors of the Best Outcomes Following Minimally Invasive Surgery for Grade 1 Degenerative Lumbar Spondylolisthesis

Neurosurgery, 87 (6) 2020: 1130–1138

The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated.

OBJECTIVE: To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis.

METHODS: A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change.

RESULTS: The mean age was 64.2 ± 11.5 yr and consisted of 148 (57.1%) women and 111(42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [−12.9 to −2.6]; P = .003), NRS back pain change (β −1.2; 95% CI [−2.1 to −0.4]; P = .004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P = .03), and NASS satisfaction (OR = 3.7; 95% CI [1.7-8.3]; P < .001). Increasing age was associated with superior NRS leg pain change (β −0.1; 95% CI [−0.1 to −0.01]; P= .03) and NASS satisfaction (OR=1.05; 95%CI [1.01-1.09]; P=.02). Fusion surgerieswere associated with superior ODI change (β −6.7; 95% CI [−12.7 to −0.7]; P= .03), NRS back pain change (β −1.1; 95% CI [−2.1 to −0.2]; P= .02), and NASS satisfaction (OR = 3.6; 95% CI [1.6-8.3]; P= .002).

CONCLUSION: Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction.

 

Posted on

Kambin’s triangle: definition and new classification schema

J Neurosurg Spine 32:390–398, 2020

Kambin’s triangle is an anatomical corridor used to access critical structures in a variety of spinal procedures. It is considered a safe space because it is devoid of vascular and neural structures of importance. Nonetheless, there is currently significant variation in the literature regarding the exact dimensions and anatomical borders of Kambin’s triangle. This confusion was originally caused by leaving the superior articular process (SAP) unassigned in the description of the working triangle, despite Kambin identifying that structure in his original report. The SAP is the most relevant structure to consider when accessing the transforaminal corridor. Leaving the SAP unassigned has led to an open-handed application of the term “Kambin’s triangle.” That single eponym currently has two potential meanings, one meaning for endoscopic surgeons working through a corridor in the intact spine and a second meaning for surgeons accessing the disc space after a complete or partial facetectomy. Nevertheless, an anatomical corridor should have one consistent definition to clearly communicate techniques and use of instrumentation performed through that space. As such, the authors propose a new surgically relevant classification of this corridor. Assigning the SAP a border requires adding another dimension to the triangle, thereby transforming it into a prism. The term “Kambin’s prism” indicates the assignment of a border to all relevant anatomical structures, allowing for a uniform definition of the 3D space. From there, the classification scheme considers the expansion of the corridor and the extent of bone removal, with a particular focus on the SAP.

Posted on

Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome

J Neurosurg Spine 31:906–913, 2019

Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

METHODS A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

RESULTS The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

CONCLUSIONS There are still insufficient data to support stem cell injections for back pain. Additional RCTs with longterm follow-up are necessary before statements can be made regarding the efficacy and safety.

 

Posted on

Outcomes of endoscopic discectomy compared with open microdiscectomy and tubular microdiscectomy for lumbar disc herniations: a meta-analysis

J Neurosurg Spine 31:802–815, 2019

Endoscopic discectomy (ED) has been advocated as a less-invasive alternative to open microdiscectomy (OM) and tubular microdiscectomy (TM) for lumbar disc herniations, with the potential to decrease postoperative pain and shorten recovery times. Large-scale, objective comparisons of outcomes between ED, OM, and TM, however, are lacking. The authors’ objective in this study was to conduct a meta-analysis comparing outcomes of ED, OM, and TM.

METHODS The PubMed database was searched for articles published as of February 1, 2019, for comparative studies reporting outcomes of some combination of ED, OM, and TM. A meta-analysis of outcome parameters was performed assuming random effects.

RESULTS Twenty-six studies describing the outcomes of 2577 patients were included. Estimated blood loss was significantly higher with OM than with both TM (p = 0.01) and ED (p < 0.00001). Length of stay was significantly longer with OM than with ED (p < 0.00001). Return to work time was significantly longer in OM than with ED (p = 0.001). Postoperative leg (p = 0.02) and back (p = 0.01) VAS scores, and Oswestry Disability Index scores (p = 0.006) at latest follow-up were significantly higher for OM than for ED. Serum creatine phosphokinase (p = 0.02) and C-reactive protein (p < 0.00001) levels on postoperative day 1 were significantly higher with OM than with ED.

CONCLUSIONS Outcomes of TM and OM for lumbar disc herniations are largely equivalent. While this analysis demonstrated that several clinical variables were significantly improved in patients undergoing ED when compared with OM, the magnitude of many of these differences was small and of uncertain clinical relevance, and several of the included studies were retrospective and subject to a high risk of bias. Further high-quality prospective studies are needed before definitive conclusions can be drawn regarding the comparative efficacy of the various surgical treatments for lumbar disc herniations.

 

Posted on

Safety and accuracy of robot-assisted versus fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery

J Neurosurg Spine 30:615–622, 2019

The object of this study was to compare the safety and accuracy of pedicle screw placement using the TiRobot system versus conventional fluoroscopy in thoracolumbar spinal surgery.

METHODS Patients with degenerative or traumatic thoracolumbar spinal disorders requiring spinal instrumentation were randomly assigned to either the TiRobot-assisted group (RG) or the freehand fluoroscopy-assisted group (FG) at a 1:1 ratio. The primary outcome measure was the accuracy of screw placement according to the Gertzbein-Robbins scale; grades A and B (pedicle breach < 2 mm) were considered clinically acceptable. In the RG, discrepancies between the planned and actual screw placements were measured by merging postoperative CT images with the trajectory planning images. Secondary outcome parameters included proximal facet joint violation, duration of surgery, intraoperative blood loss, conversion to freehand approach in the RG, postoperative hospital stay, and radiation exposure.

RESULTS A total of 1116 pedicle screws were implanted in 234 patients (119 in the FG, and 115 in the RG). In the RG, 95.3% of the screws were perfectly positioned (grade A); the remaining screws were graded B (3.4%), C (0.9%), and D (0.4%). In the FG, 86.1% screws were perfectly positioned (grade A); the remaining screws were graded B (7.4%), C (4.6%), D (1.4%), and E (0.5%). The proportion of clinically acceptable screws was significantly greater in the RG than in the FG (p < 0.01). In the RG, the mean deviation was 1.5 ± 0.8 mm for each screw. The most common direction of screw deviation was lateral in the RG and medial in the FG. Two misplaced screws in the FG required revision surgery, whereas no revision was required in the RG. None of the screws in the RG violated the proximal facet joint, whereas 12 screws (2.1%) in the FG violated the proximal facet joint (p < 0.01). The RG had significantly less blood loss (186.0 ± 255.3 ml) than the FG (217.0 ± 174.3 ml; p < 0.05). There were no significant differences between the two groups in terms of surgical time and postoperative hospital stay. The mean cumulative radiation time was 81.5 ± 38.6 seconds in the RG and 71.5 ± 44.2 seconds in the FG (p = 0.07). Surgeon radiation exposure was significantly less in the RG (21.7 ± 11.5 μSv) than in the FG (70.5 ± 42.0 μSv; p < 0.01).

CONCLUSIONS TiRobot-guided pedicle screw placement is safe and useful in thoracolumbar spinal surgery. Clinical trial registration no.: NCT02890043 (clinicaltrials.gov)

 

Posted on

Complications for minimally invasive lateral interbody arthrodesis: a systematic review and meta-analysis comparing prepsoas and transpsoas approaches

J Neurosurg Spine 30:446–460, 2019

Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.

METHODS A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.

RESULTS For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the trans-psoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.

CONCLUSIONS Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory dis- turbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.

Posted on

Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine

J Neurosurg Spine 29:397–406, 2018

Navigation-enabling technology such as 3D-platform (O-arm) or intraoperative mobile CT (iCT-Airo) systems for use in spinal surgery has considerably improved accuracy over that of traditional fluoroscopy-guided techniques during pedicular screw positioning. In this study, the authors compared 2 intraoperative imaging systems with navigation, available in their neurosurgical unit, in terms of the accuracy they provided for transpedicular screw fixation in the thoracic and lumbar spine.

METHODS The authors performed a retrospective analysis of clinical and surgical data of 263 consecutive patients who underwent thoracic and lumbar spine screw placement in the same center. Data on 97 patients who underwent surgery with iCT-Airo navigation (iCT-Airo group) and 166 with O-arm navigation (O-arm group) were analyzed. Most patients underwent surgery for a degenerative or traumatic condition that involved thoracic and lumbar pedicle screw fixation using an open or percutaneous technique. The primary endpoint was the proportion of patients with at least 1 screw not correctly positioned according to the last intraoperative image. Secondary endpoints were the proportion of screws that were repositioned during surgery, the proportion of patients with a postoperative complication related to screw malposition, surgical time, and radiation exposure. A blinded radiologist graded screw positions in the last intraoperative image according to the Heary classification (grade 1–3 screws were considered correctly placed).

RESULTS A total of 1361 screws placed in 97 patients in the iCT-Airo group (503 screws) and in 166 in the O-arm group (858 screws) were graded. Of those screws, 3 (0.6%) in the iCT-Airo group and 4 (0.5%) in the O-arm group were misplaced. No statistically significant difference in final accuracy between these 2 groups or in the subpopulation of patients who underwent percutaneous surgery was found. Three patients in the iCT-Airo group (3.1%, 95% CI 0%–6.9%) and 3 in the O-arm group (1.8%, 95% CI 0%–4.0%) had a misplaced screw (Heary grade 4 or 5). Seven (1.4%) screws in the iCT-Airo group and 37 (4.3%) in the O-arm group were repositioned intraoperatively (p = 0.003). One patient in the iCT-Airo group and 2 in the O-arm group experienced postoperative neurological deficits related to hardware malposition. The mean surgical times in both groups were similar (276 [iCT-Airo] and 279 [O-arm] minutes). The mean exposure to radiation in the iCT-Airo group was significantly lower than that in the O-arm group (15.82 vs 19.12 mSv, respectively; p = 0.02).

CONCLUSIONS Introduction of a mobile CT scanner reduced the rate of screw repositioning, which enhanced patient safety and diminished radiation exposure for patients, but it did not improve overall accuracy compared to that of a mobile 3D platform.

 

Posted on

Radiological adjacent-segment degeneration in L4–5 spondylolisthesis: comparison between dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion

J Neurosurg Spine 29:250–258, 2018

Pedicle screw–based dynamic stabilization has been an alternative to conventional lumbar fusion for the surgical management of low-grade spondylolisthesis. However, the true effect of dynamic stabilization on adjacent segment degeneration (ASD) remains undetermined. Authors of this study aimed to investigate the incidence of ASD and to compare the clinical outcomes of dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS The records of consecutive patients with Meyerding grade I degenerative spondylolisthesis who had undergone surgical management at L4–5 in the period from 2007 to 2014 were retrospectively reviewed. Patients were divided into two groups according to the surgery performed: Dynesys dynamic stabilization (DDS) group and MI-TLIF group. Pre- and postoperative radiological evaluations, including radiography, CT, and MRI studies, were compared. Adjacent discs were evaluated using 4 radiological parameters: instability (antero- or retrolisthesis), disc degeneration (Pfirrmann classification), endplate degeneration (Modic classification), and range of motion (ROM). Clinical outcomes, measured with the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the Japanese Orthopaedic Association (JOA) scores, were also compared.

RESULTS A total of 79 patients with L4–5 degenerative spondylolisthesis were included in the analysis. During a mean follow-up of 35.2 months (range 24–89 months), there were 56 patients in the DDS group and 23 in the MI-TLIF group. Prior to surgery, both groups were very similar in demographic, radiological, and clinical data. Postoperation, both groups had similarly significant improvement in clinical outcomes (VAS, ODI, and JOA scores) at each time point of evaluation. There was a lower chance of disc degeneration (Pfirrmann classification) of the adjacent discs in the DDS group than in the MI-TLIF group (17% vs 37%, p = 0.01). However, the DDS and MI-TLIF groups had similar rates of instability (15.2% vs 17.4%, respectively, p = 0.92) and endplate degeneration (1.8% vs 6.5%, p = 0.30) at the cranial (L3–4) and caudal (L5–S1) adjacent levels after surgery. The mean ROM in the cranial and caudal levels was also similar in the two groups. None of the patients required secondary surgery for any ASD (defined by radiological criteria).

CONCLUSIONS The clinical improvements after DDS were similar to those following MI-TLIF for L4–5 Meyerding grade I degenerative spondylolisthesis at 3 years postoperation. According to radiological evaluations, there was a lower chance of disc degeneration in the adjacent levels of the patients who had undergone DDS. However, other radiological signs of ASD, including instability, endplate degeneration, and ROM, were similar between the two groups. Although none of the patients in the present series required secondary surgery, a longer follow-up and a larger number of patients would be necessary to corroborate the protective effect of DDS against ASD.

Posted on

Prognostic Factors for Satisfaction After Decompression Surgery for Lumbar Spinal Stenosis

Neurosurgery 82:645–651, 2018

Surgical treatment for lumbar spinal stenosis is associated with both short- and long-term benefits with improvements in patient function and pain. Even though most patients are satisfied postoperatively, some studies report that up to onethird of patients are dissatisfied.

OBJECTIVE: To present clinical outcome data and identify prognostic factors related to patient satisfaction 1 yr after posterior decompression surgery for lumbar spinal stenosis.

METHODS: This multicenter register study included 2562 patients. Patients were treated with various types of posterior decompression. Patients with previous spine surgery or concomitant fusion were excluded. Patient satisfaction was analyzed for associations with age, sex, body mass index, smoking status, duration of pain, number of decompressed vertebral levels, comorbidities, and patient-reported outcome measures,which were used to quantify the effect of the surgical intervention.

RESULTS: At 1-yr follow-up, 62.4% of patients were satisfied but 15.1% reported dissatisfaction. The satisfied patients showed significantly greater improvement in all outcome measures compared to the dissatisfied patients. The outcome scores for the dissatisfied patients were relatively unchanged or worse compared to baseline. Association was seen between dissatisfaction, duration of leg pain, smoking status, and patient comorbidities. Patients with good walking capacity at baseline were less prone to be dissatisfied compared to patients with poor walking capacity.

CONCLUSION: This study found smoking, long duration of leg pain, and cancerous and neurological disease to be associated with patient dissatisfaction, whereas good walking capacity at baseline was positively associated with satisfaction after 1 yr.

Posted on

Prospective, randomized, multicenter study with 2-year follow-up to compare the performance of decompression with and without interlaminar stabilization

J Neurosurg Spine 28:406–415, 2018

Surgical decompression is extremely effective in relieving pain and symptoms due to lumbar spinal stenosis (LSS). Decompression with interlaminar stabilization (D+ILS) is as effective as decompression with posterolateral fusion for stenosis, as shown in a major US FDA pivotal trial. This study reports a multicenter, randomized controlled trial in which D+ILS was compared with decompression alone (DA) for treatment of moderate to severe LSS.

METHODS Under approved institutional ethics review, 230 patients (1:1 ratio) randomized to either DA or D+ILS (coflex, Paradigm Spine) were treated at 7 sites in Germany. Patients had moderate to severe LSS at 1 or 2 adjacent segments from L-3 to L-5. Outcomes were evaluated up to 2 years postoperatively, including Oswestry Disability Index (ODI) scores, the presence of secondary surgery or lumbar injections, neurological status, and the presence of device- or procedure-related severe adverse events. The composite clinical success (CCS) was defined as combining all 4 of these outcomes, a success definition validated in a US FDA pivotal trial. Additional secondary end points included visual analog scale (VAS) scores, Zürich Claudication Questionnaire (ZCQ) scores, narcotic usage, walking tolerance, and radiographs.

RESULTS The overall follow-up rate was 91% at 2 years. There were no significant differences in patient-reported outcomes at 24 months (p > 0.05). The CCS was superior for the D+ILS arm (p = 0.017). The risk of secondary intervention was 1.75 times higher among patients in the DA group than among those in the D+ILS group (p = 0.055). The DA arm had 228% more lumbar injections (4.5% for D+ILS vs 14.8% for DA; p = 0.0065) than the D+ILS one. Patients who underwent DA had a numerically higher rate of narcotic use at every time point postsurgically (16.7% for D+ILS vs 23% for DA at 24 months). Walking Distance Test results were statistically significantly different from baseline; the D+ILS group had > 2 times the improvement of the DA. The patients who underwent D+ILS had > 5 times the improvement from baseline compared with only 2 times the improvement from baseline for the DA group. Foraminal height and disc height were largely maintained in patients who underwent D+ILS, whereas patients treated with DA showed a significant decrease at 24 months postoperatively (p < 0.001).

CONCLUSIONS This study showed no significant difference in the individual patient-reported outcomes (e.g., ODI, VAS, ZCQ) between the treatments when viewed in isolation. The CCS (survivorship, ODI success, absence of neurological deterioration or device- or procedure-related severe adverse events) is statistically superior for ILS. Microsurgical D+ILS increases walking distance, decreases compensatory pain management, and maintains radiographic foraminal height, extending the durability and sustainability of a decompression procedure. Clinical trial registration no.: NCT01316211 (clinicaltrials.gov)

 

Posted on

Percutaneous transforaminal endoscopic discectomy compared with microendoscopic discectomy for lumbar disc herniation

J Neurosurg Spine 28:300–310, 2018

A prospective randomized controlled study was conducted to clarify whether percutaneous transforaminal endoscopic discectomy (PTED) results in better clinical outcomes and less surgical trauma than microendoscopic discectomy (MED).

METHODS In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed lumbar disc herniation. Patients were randomly allocated to the PTED or the MED group by computer-generated randomization codes. The primary outcome was the Oswestry Disability Index (ODI) score 1 year after surgery. Secondary outcomes included scores of the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain and physical function scales, EuroQol Group’s EQ-5D , and the visual analog scales for back pain and leg pain. Data including duration of operation, in-bed time, length of hospital stay, surgical cost and total hospital cost, complications, and reoperations were recorded.

RESULTS A total of 153 participants were randomly assigned to 2 treatment groups (PTED vs MED), and 89.5% (137 patients) completed 1 year of follow-up. Primary and secondary outcomes did not differ significantly between the treatment groups at each prespecified follow-up point (p > 0.05). For PTED, there was less postoperative improvement in ODI score in the median herniation subgroup at 1 week (p = 0.027), 3 months (p = 0.013), 6 months (p = 0.027), and 1 year (p = 0.028) compared with the paramedian subgroup. For MED, there was significantly less improvement in ODI score at 3 months (p = 0.008), 6 months (p = 0.028), and 1 year (p = 0.028) in the far-lateral herniation subgroup compared with the paramedian subgroup. The total complication rate over the course of 1 year was 13.75% in the PTED group and 16.44% in the MED group (p = 0.642). Five patients (6.25%) in the PTED group and 3 patients (4.11%) in the MED group suffered from residue/recurrence of herniation, for which reoperation was required.

CONCLUSIONS Over the 1-year follow-up period, PTED did not show superior clinical outcomes and did not seem to be a safer procedure for patients with lumbar disc herniation compared with MED. PTED had inferior results for median disc herniation, whereas MED did not seem to be the best treatment option for far-lateral disc herniation. Clinical trial registration no.: NCT01997086 (clinicaltrials.gov).

Posted on

Incidence of Adjacent Segment Disease Requiring Reoperation After Lumbar Laminectomy Without Fusion

ADJACENT SEGMENT DISEASE AFTER LUMBAR LAMINECTOMY

Neurosurgery 78:192–199, 2016

Adjacent segment disease (ASD) has not been described after laminectomy without fusion.

OBJECTIVE: To determine the incidence of ASD after a 1- or 2-level lumbar laminectomy.

METHODS: We retrospectively reviewed medical records of all patients who underwent 1- or 2-level, bilateral lumbar laminectomy without fusion for degenerative spinal disease (all follow-up $1 year). ASD was defined as clinical and/or radiographic evidence of degenerative spinal disease that required reoperation at the level above or below the index laminectomy.

RESULTS: Of the 398 patients, the incidence of ASD requiring reoperation was 10%. The 39 ASD cases were almost equally distributed at L2-L3 (31%), L3-L4 (26%), and L5-S1 (31%), and to a lesser extent at L4-L5 (15%) (P = .51). The ASD incidences of 10% and 9% were equivalent after a 1- and 2-level laminectomy, respectively (P = .76). Rostral ASD was statistically more common than caudal ASD after both the 1- (P , .001) and 2- (P , .001) level laminectomy. Of the 39 ASD cases, 95% required laminectomy, 26% discectomy, and 49% fusion. Average time to ASD was 4 years. After a Kaplan-Meier analysis, time to reoperation for ASD was equivalent among the 1- and 2-level laminectomy cohorts (log-rank test, P = .13).

CONCLUSION: The cumulative incidence of ASD requiring reoperation was 10% over a mean of 4 years. Both the 1- and 2-level laminectomy cohorts experienced equivalent incidences and rates of ASD. Of the 39 operations for ASD, about half required a fusion.

Posted on

Subsidence after lateral interbody fusion

Assessment and classi cation of subsidence after lateral interbody fusion using serial computed tomography

J Neurosurg Spine 23:589–597, 2015

Intervertebral cage settling during bone remodeling after lumbar lateral interbody fusion (LIF) is a common occurrence during the normal healing process. Progression of this settling with endplate collapse is defined as subsidence. The purposes of this study were to 1) assess the rate of subsidence after minimally invasive (MIS) LIF by CT, 2) distinguish between early cage subsidence (ECS) and delayed cage subsidence (DCS), 3) propose a descriptive method for classifying the types of subsidence, and 4) discuss techniques for mitigating the risk of subsidence after MIS LIF.

Methods A total of 128 consecutive patients (with 178 treated levels in total) underwent MIS LIF performed by a single surgeon. The subsidence was deemed to be ECS if it was evident on postoperative Day 2 CT images and was therefore the result of an intraoperative vertebral endplate injury and deemed DCS if it was detected on subsequent CT scans (≥ 6 months postoperatively). Endplate breaches were categorized as caudal (superior endplate) and/or cranial (inferior endplate), and as ipsilateral, contralateral, or bilateral with respect to the side of cage insertion. Subsidence seen in CT images (radiographic subsidence) was measured from the vertebral endplate to the caudal or cranial margin of the cage (in millimeters). Patient-reported outcome measures included visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey physical and mental component summary scores.

Results Four patients had ECS in a total of 4 levels. The radiographic subsidence (DCS) rates were 10% (13 of 128 patients) and 8% (14 of 178 levels), with 3% of patients (4 of 128) exhibiting clinical subsidence. In the DCS levels, 3 types of subsidence were evident on coronal and sagittal CT scans: Type 1, caudal contralateral, in 14% (2 of 14), Type 2, caudal bilateral with anterior cage tilt, in 64% (9 of 14), and Type 3, both endplates bilaterally, in 21% (3 of 14). The mean subsidence in the DCS levels was 3.2 mm. There was no significant difference between the numbers of patients in the subsidence (DCS) and no-subsidence groups who received clinical benefit from the surgical procedure, based on the minimum clinically important difference (p > 0.05). There was a significant difference between the fusion rates at 6 months (p = 0.0195); however, by 12 months, the difference was not significant (p = 0.2049).

Conclusions The authors distinguished between ECS and DCS. Radiographic subsidence (DCS) was categorized using descriptors for the location and severity of the subsidence. Neither interbody fusion rates nor clinical outcomes were affected by radiographic subsidence. To protect patients from subsidence after MIS LIF, the surgeon needs to take care with the caudal endplate during cage insertion. If a caudal bilateral (Type 2) endplate breach is detected, supplemental posterior fixation to arrest progression and facilitate fusion is recommended.

Posted on

Surgical treatment of pathological loss of lumbar lordosis (flatback)

Flatback

J Neurosurg Spine 21:160–170, 2014

Increased sagittal vertical axis (SVA) correlates strongly with pain and disability for adults with spinal deformity. A subset of patients with sagittal spinopelvic malalignment (SSM) have flatback deformity (pelvic incidence–lumbar lordosis [PI-LL] mismatch > 10°) but remain sagittally compensated with normal SVA. Few data exist for SSM patients with flatback deformity and normal SVA. The authors’ objective was to compare baseline disability and treatment outcomes for patients with compensated (SVA < 5 cm and PI-LL mismatch > 10°) and decompensated (SVA > 5 cm) SSM.

Methods. The study was a multicenter, prospective analysis of adults with spinal deformity who consecutively underwent surgical treatment for SSM. Inclusion criteria included age older than 18 years, presence of adult spinal deformity with SSM, plan for surgical treatment, and minimum 1-year follow-up data. Patients with SSM were divided into 2 groups: those with compensated SSM (SVA < 5 cm and PI-LL mismatch > 10°) and those with decompensated SSM (SVA ≥ 5 cm). Baseline and 1-year follow-up radiographic and health-related quality of life (HRQOL) outcomes included Oswestry Disability Index, Short Form–36 scores, and Scoliosis Research Society–22 scores. Percentages of patients achieving minimal clinically important difference (MCID) were also assessed.

Results. A total of 125 patients (27 compensated and 98 decompensated) met inclusion criteria. Compared with patients in the compensated group, patients in the decompensated group were older (62.9 vs 55.1 years; p = 0.004) and had less scoliosis (43° vs 54°; p = 0.002), greater SVA (12.0 cm vs 1.7 cm; p < 0.001), greater PI-LL mismatch (26° vs 20°; p = 0.013), and poorer HRQOL scores (Oswestry Disability Index, Short Form-36 physical component score, Scoliosis Research Society-22 total; p ≤ 0.016). Although these baseline HRQOL differences between the groups reached statistical significance, only the mean difference in Short Form–36 physical component score reached threshold for MCID. Compared with baseline assessment, at 1 year after surgery improvement was noted for patients in both groups for mean SVA (compensated –1.1 cm, decompensated +4.8 cm; p ≤ 0.009), mean PI-LL mismatch (compensated 6°, decompensated 5°; p < 0.001), and all HRQOL measures assessed (p ≤ 0.005). No significant differences were found between the compensated and decompensated groups in the magnitude of HRQOL score improvement or in the percentages of patients achieving MCID for each of the outcome measures assessed.

Conclusions. Decompensated SSM patients with elevated SVA experience significant disability; however, the amount of disability in compensated SSM patients with flatback deformity caused by PI-LL mismatch but normal SVA is underappreciated. Surgical correction of SSM demonstrated similar radiographic and HRQOL score improvements for patients in both groups. Evaluation of SSM should extend beyond measuring SVA. Among patients with concordant pain and disability, PI-LL mismatch must be evaluated for SSM patients and can be considered a primary indication for surgery.

Posted on

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Neurosurg Focus 37 (1):E11, 2014

Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective.

In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques.

These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques.

While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma.

Posted on

Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine


Robot-assisted spine surgery

J Neurosurg Spine 20:636–643, 2014

Recent years have been marked by efforts to improve the quality and safety of pedicle screw placement in spinal instrumentation. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement.

Methods. Ninety-five patients suffering from degenerative disease and requiring elective lumbar instrumentation were included in the study. The robot cohort (Group I; 55 patients, 244 screws) consisted of an initial open robot-assisted subgroup (Subgroup IA; 17 patients, 83 screws) and a percutaneous cohort (Subgroup IB, 38 patients, 161 screws). In these groups, pedicle screws were placed under robotic guidance and lateral fluoroscopic control. In the fluoroscopy-guided cohort (Group II; 40 patients, 163 screws) screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The primary outcome measure was accuracy of screw placement on the Gertzbein-Robbins scale (Grade A to E and R [revised]). Secondary parameters were duration of surgery, blood loss, cumulative morphine, and length of stay.

Results. In the robot group (Group I), a perfect trajectory (A) was observed in 204 screws (83.6%). The remaining screws were graded B (n = 19 [7.8%]), C (n = 9 [3.7%]), D (n = 4 [1.6%]), E (n = 2 [0.8%]), and R ( n = 6 [2.5%]). In the fluoroscopy-guided group (Group II), a completely intrapedicular course graded A was found in 79.8% (n = 130). The remaining screws were graded B (n = 12 [7.4%]), C (n = 10 [6.1%]), D (n = 6 [3.7%]), and E (n = 5 [3.1%]). The comparison of “clinically acceptable” (that is, A and B screws) was neither different between groups (I vs II [p = 0.19]) nor subgroups (Subgroup IA vs IB [p = 0.81]; Subgroup IA vs Group II [p = 0.53]; Subgroup IB vs Group II [p = 0.20]). Blood loss was lower in the robot-assisted group than in the fluoroscopy-guided group, while duration of surgery, length of stay, and cumulative morphine dose were not statistically different.

Conclusions. Robot-guided pedicle screw placement is a safe and useful tool for assisting spine surgeons in degenerative spine cases. Nonetheless, technical difficulties remain and fluoroscopy backup is advocated.

Posted on

Reoperation Rate After Surgery for Lumbar Herniated Intervertebral Disc Disease

herniated_disc

Spine 2013 ; 38 : 581 – 590

Retrospective cohort study using national health insurance data.

Objective. To provide a longitudinal reoperation rate after surgery for lumbar herniated intervertebral disc (HIVD) disease, and to compare the reoperation rates of surgical methods.

Summary of Background Data. Herniated intervertebral disc disease is the most common cause of lumbar spinal surgery. Despite improved surgical techniques and instrumentation, reoperation cannot be avoided. The reoperation rates were in the range of 6% to 24% in previous studies. A population-based study is less subject to bias; hence, a nationwide longitudinal analysis was warranted.

Methods. A national health insurance database was used to identify a cohort of patients who underwent fi rst surgery for herniated intervertebral disc disease in 2003 and 18,590 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. The primary endpoint was any type of second lumbar surgery. After adjusting for confounding factors, 5 surgical methods (fusion, laminectomy, open discectomy, endoscopic discectomy, and nucleolysis [including mechanical nucleus decompression]) were compared. Open discectomy was used as the reference method.

Results. Open discectomy was the most common procedure (68.9%) followed by endoscopic discectomy (16.1%), laminectomy (7.9%), fusion (3.9%), and nucleolysis (3.2%). The cumulative reoperation rate was 5.4% at 3 months, 7.4% at 1 year, 9% at 2 years, 10.5% at 3 years, 12.1% at 4 years, and 13.4% at 5 years. The reoperation rates were 18.6%, 14.7%, 13.8%, 12.4%, and 11.8% after laminectomy, nucleolysis, open discectomy, endoscopic discectomy, and fusion, respectively. Compared with open discectomy, the reoperation rate was higher after laminectomy at 3 months, whereas the other surgical methods had similar rates.

Conclusion. The cumulative reoperation rate after 5 years was 13.4% and half of the reoperations occurred during the fi rst postoperative year. With the exception of laminectomy, the reoperation rates of the other procedures were not different from that of open discectomy.

Posted on

Accuracy of Free-Hand Pedicle Screws in the Thoracic and Lumbar Spine: Analysis of 6816 Consecutive Screws

Neurosurgery 68:170–178, 2011 DOI: 10.1227/NEU.0b013e3181fdfaf4

Pedicle screws are used to stabilize all 3 columns of the spine, but can be technically demanding to place. Although intraoperative fluoroscopy and stereotactic- guided techniques slightly increase placement accuracy, they are also associated with increased radiation exposure to patient and surgeon as well as increased operative time.

OBJECTIVE: To describe and critically evaluate our 7-year institutional experience with placement of pedicle screws in the thoracic and lumbar spine using a free-hand technique.

METHODS: We retrospectively reviewed records of all patients undergoing free-hand pedicle screw placement without fluoroscopy in the thoracic or lumbar spine between June 2002 and June 2009. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of postoperative computed tomography scans. We defined breach as more than 25% of the screw diameter residing outside of the pedicle or vertebral body cortex.

RESULTS: A total of 964 patients received 6816 free-hand placed pedicle screws in the thoracic or lumbar spine. Indications for hardware placement were degenerative/deformity disease (51.2%), spondylolisthesis (23.7%), tumor (22.7%), trauma (11.3%), infection (7.6%), and congenital (0.9%). A total of 115 screws (1.7%) were identified as breaching the pedicle in 87 patients (9.0%). Breach occurred more frequently in the thoracic than the lumbar spine (2.5% and 0.9%, respectively; P , .0001) and was more often lateral (61.3%) than medial (32.8%) or superior (2.5%). T4 (4.1%) and T6 (4.0%) experienced the highest breach rate, whereas L5 and S1 had the lowest breach rate. Eight patients (0.8%) underwent revision surgery to correct malpositioned screws.

CONCLUSION: Free-hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy and allows avoidance of radiation exposure encountered in fluoroscopic techniques. Image-guided assistance may be most valuable when placing screws between T4 and T6, where breach rates are highest

Proudly powered by WordPress