Retrospective cohort analysis.
To compare postoperative outcomes of Coflex interspinous device versus laminectomy.
Coflex Interlaminar Stabilization ® device (CID) is indicated for one- or two-level ...lumbar stenosis with grade 1 stable spondylolisthesis in adult patients, as an alternative to laminectomy, or laminectomy and fusion. CID provides stability against progressive spondylolisthesis, retains motion, and prevents further disc space collapse.
Patients ≥18 years-old with lumbar stenosis and grade 1 stable spondylolisthesis who underwent either primary single-level decompression and implantation of CID; or single-level laminectomy alone were included with a minimum 90 day follow up at a single academic institution. Clinical characteristics, perioperative outcomes, and postoperative complications were reviewed until the latest follow-up. Chi-square and independent samples t tests were used for analysis.
83 patients (2007-2019) were included: 37 cases of single-level laminectomy (48.6% female) were compared to 46 single-level CID (50% female). CID cohort was older (CID 69.0 ± 9.4 vs Laminectomy 64.2 ± 11.0, p = 0.042) and had higher American Society of Anesthesiologists (ASA) grade (CID 2.59 ± 0.73 vs Laminectomy 2.17 ± 0.48, p = 0.020). CID patients had higher estimated blood loss (97.50 ± 77.76 vs 52.84 ± 50.63 mL, p = 0.004), longer operative time (141.91 ± 47.88 vs 106.81 ± 41.30 min, p = 0.001), and longer length of stay (2.0 ± 1.5 vs 1.1 ± 1.0 days, p = 0.001). Total perioperative complications (21.7% vs 5.4%, p = 0.035) and instrumentation related complication was higher in CID (10.9% vs 0% laminectomy group, p = 0.039). There were no other significant differences between the groups in demographics or outcomes.
Single level CID devices had higher perioperative 90-day complications, longer operative time, length of stay, higher estimated blood loss compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow up.Level of Evidence: 3.
The COVID-19 pandemic caused nationwide suspensions of elective surgeries due to reallocation of resources to the care of COVID-19 patients. Following resumption of elective cases, a significant ...proportion of patients continued to delay surgery, with many yet to reschedule, potentially prolonging their pain and impairment of function and causing detrimental long-term effects.
The aim of this study was to examine differences between patients who have and have not rescheduled their spine surgery procedures originally cancelled due to the COVID-19 pandemic, and to evaluate the reasons for continued deferment of spine surgeries even after the lifting of the mandated suspension of elective surgeries.
Retrospective case series at a single institution
Included were 133 patients seen at a single institution where spine surgery was canceled due to a state-mandated suspension of elective surgeries from March to June, 2020.
The measures assessed included preoperative diagnoses and neurological dysfunction, surgical characteristics, reasons for surgery deferment, and PROMIS scores of pain intensity, pain interference, and physical function.
Patient electronic medical records were reviewed. Patients who had not rescheduled their canceled surgery as of January 31, 2021, and did not have a reason noted in their charts were called to determine the reason for continued surgery deferment. Patients were divided into three groups: early rescheduled (ER), late rescheduled (LR), and not rescheduled (NR). ER patients had a date of surgery (DOS) prior to the city's Phase 4 reopening on July 20, 2020; LR patients had a DOS on or after that date. Statistical analysis of the group findings included analysis of variance with Tukey's honestly significant difference (HSD) post-hoc test, independent samples T-test, and chi-square analysis with significance set at p≤.05.
Out of 133 patients, 47.4% (63) were in the ER, 15.8% (21) in the LR, and 36.8% (49) in the NR groups. Demographics and baseline PROMIS scores were similar between groups. LR had more levels fused (3.6) than ER (1.6), p= .018 on Tukey HSD. NR (2.1) did not have different mean levels fused than LR or ER, both p= >.05 on Tukey HSD. LR had more three column osteotomies (14.3%) than ER and (1.6%) and NR (2.0%) p=.022, and fewer lumbar microdiscectomies (0%) compared to ER (20.6%) and NR (10.2%), p=.039. Other surgical characteristics were similar between groups. LR had a longer length of stay than ER (4.2 vs 2.4, p=.036). No patients in ER or LR had a nosocomial COVID-19 infection. Of NR, 2.0% have a future surgery date scheduled and 8.2% (4) are acquiring updated exams before rescheduling. 40.8% (20; 15.0% total cohort) continue to defer surgery over concern for COVID-19 exposure and 16.3% (8) for medical comorbidities. 6.1% (3) permanently canceled for symptom improvement. 8.2% (4) had follow-up recommendations for non-surgical management. 4.1% (2) are since deceased.
Over 1/3 of elective spine surgeries canceled due to COVID-19 have not been performed in the 8 months from when elective surgeries resumed in our institution to the end of the study. ER patients had less complex surgeries planned than LR. NR patients continue to defer surgery primarily over concern for COVID-19 exposure. The toll on the health of these patients as a result of the delay in treatment and on their lives due to their inability to return to normal function remains to be seen.
Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly common procedure for the treatment of lumbar degenerative pathologies. The MIS-TLIF technique often ...results in less soft-tissue injury compared with the open TLIF technique, reducing postoperative pain and recovery time
. However, the narrow surgical aperture of this minimally invasive technique has increased the difficulty of interbody cage placement. Expandable cages were designed to improve ease of insertion, improve visualization around the cage on insertion, reduce neurological retraction and injury by passing the nerve root with the implant in a collapsed state, and enable better disc-height and lordosis restoration on expansion
.
This procedure is performed with the patient under general anesthesia and in a prone position. The appropriate spinal level is identified with use of fluoroscopy, and bilateral paramidline approaches are made utilizing the Wiltse intermuscular approach. Pedicle screws are placed bilaterally. A pedicle-based retractor or tubular retractor is passed along the Wiltse plane, and bilateral inferior facetectomies are performed. A foraminotomy is performed, including a superior facetectomy on the side with compression of the exiting nerve root. A thorough discectomy with end-plate preparation is performed. The disc space is sized with use of trial components. The cage is then implanted with a pre-expansion height less than the trialed height and is expanded under fluoroscopy. After expansion, the cage is backfilled with allograft and local autograft. Finally, the rods are contoured and reduced bilaterally, followed by closure in a multilayered approach.
Nonoperative alternatives to the minimally invasive TLIF technique include physical therapy or epidural corticosteroid injections. When surgical intervention is indicated, there are several approaches that can be utilized during lumbar interbody fusion, including the posterior, direct lateral, anterior, or oblique approaches
.
Expandable cages are designed to be inserted in a collapsed configuration and expanded once placed into the interbody space. This design offers numerous potential advantages over static alternatives. The low-profile, expandable cages require less impaction during placement, minimizing iatrogenic end-plate damage. Additionally, expandable cages require less thecal and nerve-root retraction and provide a larger surface footprint once expanded.
The MIS-TLIF technique has been shown to significantly reduce back pain, leg pain, and disability, and to significantly increase function, with most improvements observed after 12 months postoperatively. Patients may experience a 51% and 39% reduction in visual analogue pain scores and Oswestry Disability Index scores, respectively
. The results for expandable cages compared with traditional static cages in TLIF surgery require further study.
The technique utilized during insertion and placement of interbody cages plays an important role in cage subsidence. To reduce the risk of cage subsidence, cages should be placed level with the end plate and in contact with the apophyseal ring anteriorly. Additionally, caution should be taken when expanding the cage to ensure that the cage is not overexpanded, which may also increase the risk of mechanical failure and intraoperative subsidence.It is critical to understand the flexibility of the disc space and the osseous quality of the patient in order to know how much expansion may be applied through the cage without subsidence.If bullet-type cages are utilized, the tip of the cage should cross midline of the vertebral body to avoid generating iatrogenic scoliosis.Spine bone density should be investigated preoperatively in at-risk patients in order to identify osteoporotic patients, who are at greater risk for subsidence and instrumentation failure.Although advances in device technology are welcomed, surgeons should maintain a strong focus on technique to reduce complications and improve clinical outcomes when utilizing expandable cages.
TLIF = transforaminal lumbar interbody fusionMIS = minimally invasive surgeryALIF = anterior lumbar interbody fusionMRI = magnetic resonance imagingCT = computed tomographyPEEK = polyetheretherketoneAP = anterioposteriorEMG = electromyographyDVT = deep vein thrombosisPE = pulmonary embolusODI = Oswestry Disability IndexEXP = expandable.
Abstract Background context: Degenerative lumbar stenosis (DLS) patients have been reported to lean forward in an attempt to provide neural decompression. Spinal alignment in patients with DLS may ...resemble that of adult spinal deformity (ASD). No previous studies have compared and contrasted the compensatory mechanisms of DLS and ASD patients. Purpose: To determine the differences in compensatory mechanisms between DLS and ASD patients with increasing severity of sagittal spino-pelvic malalignment. Contrasting these compensatory mechanisms may help determine at what severity sagittal malalignment represents a clinical sagittal deformity rather than a compensation for neural compression. Study Design/Setting: Retrospective clinical and radiological review Patient Sample: Baseline x-rays in patients without spinal instrumentation, with the clinical radiological and diagnoses of DLS or ASD were assessed for patterns of spino-pelvic compensatory mechanisms. Patients were stratified by sagittal vertical axis (SVA) by the Schwab-SRS classification. Outcome Measures: Radiographic spino-pelvic parameters were measured in the DLS and ASD groups, including SVA, PI-LL, T1SPi, TPA and PT Methods The two diagnosis cohorts were propensity matched for pelvic incidence and age. Each group contained 125 patients. Each group was stratified according to the SRS-Schwab classification. Regional spino-pelvic, lower limb and global alignment parameters were assessed in each group to identify differences in compensatory mechanisms between the two groups with differing degrees of deformity. No funding was provided by any third party in relation to carrying out this study or preparation of the manuscript. Results With mild to moderate malalignment (SRS-Schwab groups ‘0’, or ‘+’ for pelvic tilt, pelvic incidence-lumbar lordosis mismatch or sagittal vertical axis), DLS patients permit anterior truncal inclination and recruit posterior pelvic shift instead of pelvic tilt to maintain balance, while providing relief of neurological symptoms. ASD patients with mild- moderate deformity recruit pelvic tilt earlier than DLS patients. With moderate- severe malalignment, no significant difference was found in compensatory mechanisms between DLS and ASD patients. Conclusions Patients with degenerative lumbar stenosis permit mild-moderate deformity without recruiting compensatory mechanisms of pelvic tilt, reducing truncal inclination and thoracic hypokyphosis in order to achieve neural decompression. However with moderate to severe deformity, their desire for upright posture overrides the desire for neural decompression, evident by the adaptation of compensatory mechanisms similar to that of the adult spinal deformity patients.
STUDY DESIGN.Retrospective analysis of three prospectively collected databases.
OBJECTIVE.To compare perioperative outcomes in Adult Spinal Deformity (ASD) surgeries in a surgeon-run (SR-ASD) and two ...national databasesthe Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP).
SUMMARY OF BACKGROUND DATA.Much has been learned on the treatment of ASD in the last decade with prospective multicenter collaborative research focusing on this specific condition. Nondisease specific national databases are being used for hypothesis and quality control testing on a large number of ASD patients. Their accuracy and applicability remains unevaluated.
METHODS.Patients were identified on each respective database undergoing lumbar spine fusion for ASD. Propensity score matching established cohorts of patients on each database with similar procedures being performed. Complication prevalence and relative risk was compared on the NIS and NSQIP against SR-ASD. Secondary outcome measures included hospital-stay characteristics, surgical invasiveness, patient demographics, and patient comorbidities.
RESULTS.Two hundred fifty-five patients were identified on each database 1:1:1 with similar overall surgical intensity. Querying the databases using ICD-9 codes, CPT codes, and surgeon-reports resulted in different complication incidencesoverall complication rates were 17.65% on NIS, 24.31% on NSQIP, and 68.24% on SR-ASD. The relative risk of a medical complication in SR-ASD was 1.87 (1.42–2.48) relative to NIS and 1.91 (1.44–2.54) relative to NSQIP. The relative risk of a surgical complication was 5.45 (2.69–11.05) compared with NIS and 12.05 (3.98–36.49) compared with NSQIP.
CONCLUSION.After selecting patients using the same criteria and diagnosis, NIS, NSQIP, and SR-ASD databases captured different patient populations and different complication incidences. There were total absences of certain complications contrary to usual literature rates in all three databases. Faithful reporting necessitates understanding database limitations, and careful evaluation of database strengths and weaknesses is paramount to accurate reports.Level of Evidence3
STUDY DESIGN.Observational cohort study of prospective database registry.
OBJECTIVE.To determine the incidence of neurological complications in AIS patients undergoing surgical treatment with PO.
...SUMMARY OF BACKGROUND DATA.Despite the widespread use of Ponte Osteotomies (PO) in adolescent idiopathic scoliosis (AIS) correction, outcomes and complications in patients treated with this technique have not been well characterized.
METHODS.A multicenter prospective registry of patients undergoing surgical correction of AIS was queried at 2-year follow-up for patient demographics, surgical data, deformity characteristics, and peri-operative complications. A neurological complication was defined as perioperative nerve root or spinal cord injury as identified by the surgeon. Patients were divided into those who underwent peri-apical PO and those without, and further stratified by Lenke curve classification into 3 groups (I-types 1 and 2, II-types 3, 4, 6, and III-type 5). Patients with- and without neurological complications were compared with respect to baseline demographics, surgical variables, curve types, fusion construct types (screws vs. hybrid), curve magnitude (coronal and sagittal Cobb), apical vertebral translation, and coronal-deformity angular ratios (C-DAR).
RESULTS.Of 2210 patients included in the study, 1611 underwent PO. Peri-operative neurological complications occurred in 7 patients, with 6 in the PO group (0.37%) and 1 in non-PO group (0.17%) though this was not a statistically significant risk factor for peri-operative neurological injury (P = 0.45). Neuromonitoring alerts were recorded in 168 patients (7.6%9.3% PO group; 4.2% no-PO group (P < 0.001)). Multivariate logistic regression analysis found PO and curve magnitude to be independent risk factors for intraoperative neuromonitoring alerts (P < 0.01).
CONCLUSION.PO and curve magnitude were independent risk factors for intraoperative neuromonitoring alerts in surgical AIS correction. The effect of Ponte osteotomy on neurological complications remains unknown due to the low incidence of these complications.Level of Evidence3
STUDY DESIGN.Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients.
OBJECTIVE.The aim of this study was to compare baseline and postoperative ...outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery.
SUMMARY OF BACKGROUND DATA.Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states.
METHODS.Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery THA, TKA) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures.
RESULTS.A total of 304 spine surgery patients (age = 58.1 ± 15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ± 11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function (21.0, 22.2, 9.07, 12.6, 10.4 vs. 35.8, 35.0, respectively, P < 0.01), pain interference (80.1, 74.1, 89.6, 92.5, 90.6 vs. 64.0, 63.9, respectively, P < 0.01), and pain intensity (53.0, 53.1, 58.3, 58.5, 56.1 vs. 53.4, 53.8, respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function (+8.7, +22.2, +9.7, +12.9, +12.1 vs. +5.3, +3.9, respectively, P < 0.01) and pain interference scores (−15.4,−28.1, −14.7, −13.1, −12.3 vs. −8.3, −6.0, respectively, P < 0.01).
CONCLUSION.Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients.Level of Evidence3
There are no studies to date analyzing the effect of spinal malalignment on outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity compensatory mechanism for ...maintaining sagittal balance with increasing spinal deformity. The purpose of this study was to determine whether a subset of patients with poor range of motion (ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion contractures and stiffness.
We retrospectively evaluated a consecutive series of patients who underwent manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length biplanar images, knee alignment and spinopelvic parameters were measured. Patients were stratified by pelvic incidence minus lumbar lordosis as a measure of spinal sagittal alignment with a mismatch of ≥10° defined as abnormal, and we calculated the incidence of sagittal spinal deformity.
Average ROM before MUA was extension 3° and flexion 83°. About 62% of patients had a pelvic incidence minus lumbar lordosis mismatch of ≥10°. In the spinal deformity group, post-MUA ROM was improved for flexion only, whereas both flexion and extension were improved in the nondeformity group.
Compensatory knee flexion because of sagittal spinal deformity may predispose to poor ROM after TKA. Patients with clinical suspicion should be worked up preoperatively and counseled accordingly.
Abstract
BACKGROUND
Patients undergoing multilevel spine surgery are at risk for delayed extubation.
OBJECTIVE
To evaluate the impact of type and volume of intraoperative fluids administered during ...multilevel thoracic and/or lumbar spine surgery on postoperative extubation status.
METHODS
Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status.
RESULTS
A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = –0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = –0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05).
CONCLUSION
PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.
The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common ...complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.
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