Among patients with spondylolisthesis and lumbar spinal stenosis, laminectomy with fusion was associated with modestly greater improvement in physical health–related quality of life than laminectomy ...alone but not with significantly greater reduction in disability related to back pain.
The increased use of the lumbar spinal fusion procedure in the United States, along with the wide variation in practice, is attracting interest from multiple stakeholders, including patients, physicians, payers, and policymakers. In a report published in 2014, spinal fusion (465,000 hospital-based procedures in 2011) accounted for the highest aggregate hospital costs ($12.8 billion in 2011) of any surgical procedure performed in U.S. hospitals.
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The randomized, controlled Spine Patient Outcomes Research Trial (SPORT) showed that surgery was superior to nonoperative care for the management of lumbar degenerative spondylolisthesis.
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In SPORT, most patients in the surgical group were treated by means . . .
Various factors related to predict surgical success were studied; however, a standard cut-off point for the Pain Sensitivity Questionnaire (PSQ) measure has not yet been established for a favorable ...surgical outcome for lumbar disc herniation (LDH). This study was to find the optimal cut-off point on the PSQ to distinguish surgical success in patients with LDH. A total of 154 patients with LDH consecutively referred to our clinic were enrolled into this prospective study between February 2011 and January 2014. All participants completed the PSQ. Patients completed the Oswestry Disability Index (ODI) score before surgery, and at 2 years after surgery. Surgical success was defined as a 13-point improvement from the baseline ODI scores. The cut-off value for PSQ was determined by the receiver-operating characteristic curve (ROC). The mean age of patients was 49.3±9.6 years, and there were 80 women. The mean time for follow-up assessment was 31±5 months (range 24-35). Post-surgical success was 79.9% (n = 123) at 2 years follow up. The mean score for the total PSQ, PSQ-minor, and PSQ-moderate were 6.0 (SD = 1.6), 5.4 (SD = 1.9) and 6.5 (SD = 1.7), respectively. Total PSQ score was also significantly correlated with the total scores of the ODI. The optimal total PSQ cut-off point was determined as > 5.2 to predict surgical success in LDH patients, with 80.0% sensitivity and 75.6% specificity (AUC-0.814, 95% CI 0.703-0.926). This study showed that the PSQ could be considered a parameter for predicting surgical success in patients with LDH, and can be useful in clinical practice.
STUDY DESIGN.Retrospective review of electronic medical records (EMR).
OBJECTIVE.This study aims to (1) characterize the pattern of opioid utilization in patients undergoing spine surgery and (2) ...compare the postoperative course between patients with and without chronic preoperative opioid prescriptions.
SUMMARY OF BACKGROUND DATA.Postoperative pain management for patients with a history of opioid usage remains a challenge for spine surgeons. Opioids are controversial in this setting due to side effects and potential for abuse and addiction. Given the increasing rate of opioid prescriptions for spine-related pain, more studies are needed to evaluate patterns and risks of preoperative opioid usage in surgical patients.
METHODS.EMR were reviewed for patients (age > 18) with lumbar spinal stenosis undergoing lumbar laminectomy in 2011 at our institution. Data regarding patient demographics, levels operated, pre/postoperative medications, and in-hospital length of stay were collected. Primary outcomes were length of stay and duration of postoperative opioid usage.
RESULTS.One hundred patients were reviewed. Fifty-five patients had a chronic opioid prescription documented at least 3 months before surgery. Forty-five patients were not on chronic opioid therapy preoperatively. The preoperative opioid group compared with the non-opioid group had a greater proportion of females (53% vs. 40%), younger mean age (63 yrs vs. 65 yrs), higher frequency of preoperative benzodiazepine prescription (20% vs. 11%), longer average in-hospital length of stay (3.7 d vs. 3.2 d), and longer duration on postoperative opioids (211 d vs. 79 d).
CONCLUSION.Patients on chronic opioids prior to spine surgery are more likely to have a longer hospital stay and continue on opioids for a longer time after surgery, compared with patients not on chronic opioid therapy. Spine surgeons and pain specialists should seek to identify patients on chronic opioids before surgery and evaluate strategies to optimize pain management in the pre- and postoperative course.Level of Evidence3
Purpose
The purpose of this systematic review and meta-analysis was to compare the cervical sagittal parameters between patients with cervical spine disorder and asymptomatic controls.
Methods
Two ...independent authors systematically searched online databases including Pubmed, Scopus, Cochrane library, and Web of Science up to June 2020. Cervical sagittal balance parameters, such as T1 slope, cervical SVA (cSVA), and spine cranial angle (SCA), were compared between the cervical spine in healthy, symptomatic, and pre-operative participants. Where possible, we pooled data using random-effects meta-analysis, by CMA software. Heterogeneity and publication bias were assessed using the I-squared statistic and funnel plots, respectively.
Results
A total of 102 studies, comprising 13,802 cases (52.7% female), were included in this meta-analysis. We used the Newcastle–Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Funnel plot and Begg’s test did not indicate obvious publication bias. The pooled analysis reveals that the mean (SD) values were: T1 slope (degree), 24.5 (0.98), 25.7 (0.99), 25.4 (0.34); cSVA (mm), 18.7 (1.76), 22.7 (0.66), 22.4 (0.68) for healthy population, symptomatic, and pre-operative assessment, respectively. The mean value of the SCA (degree) was 79.5 (3.55) and 75.6 (10.3) for healthy and symptomatic groups, respectively. Statistical differences were observed between the groups (all
P
values < 0.001).
Conclusion
The findings showed that the T1 slope and the cSVA were significantly lower among patients with cervical spine disorder compared to controls and higher for the SCA. Further well-conducted studies are needed to complement our findings.
STUDY DESIGN.Prospective observational cohort study.
OBJECTIVE.To determine if postoperative cervical sagittal balance is an independent predictor of health-related quality of life outcome after ...surgery for cervical spondylotic myelopathy.
SUMMARY OF BACKGROUND DATA.Both ventral and dorsal fusion procedures for CSM are effective at reducing the symptoms of myelopathy. The importance of cervical sagittal balance in predicting overall health-related quality of life outcome after ventral versus dorsal surgery for CSM has not been previously explored.
METHODS.A prospective, nonrandomized cohort of 49 patients undergoing dorsal and ventral fusion surgery for CSM was examined. Preoperative and postoperative C2–C7 sagittal vertical axis was measured on standing lateral cervical spine radiographs. Outcome was assessed with 2 disease-specific measures—the modified Japanese Orthopedic Association scale and the Oswestry Neck Disability Index and 2 generalized outcome measures—the Short-Form 36 physical component summary (SF-36 PCS) and Euro-QOL-5D. Assessments were performed preoperatively, and at 3 months, 6 months, and 1 year postoperatively. Statistical analyses were performed using SAS version 9.3 (SAS Institute).
RESULTS.Most patients experienced improvement in all outcome measures regardless of approach. Both preoperative and postoperative C2–C7 sagittal vertical axis measurements were independent predictors of clinically significant improvement in SF-36 PCS scores (P = 0.03 and P = 0.02). The majority of patients with C2–C7 sagittal vertical axis values greater than 40 mm did not improve from an overall health-related quality of life perspective (SF-36 PCS) despite improvement in myelopathy. The postoperative sagittal balance value was inversely correlated with a clinically significant improvement of SF-36 PCS scores in patients undergoing dorsal surgery but not ventral surgery (P = 0.03 vs. P = 0.93).
CONCLUSION.Preoperative and postoperative sagittal balance measurements independently predict clinical outcomes after surgery for CSM.Level of Evidence2
Abstract Background context Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for patients presenting with cervical radiculopathy, myelopathy, or deformity. A ...systematic literature review and meta-analysis of pseudoarthrosis rates associated with ACDF with plate fixation have not been previously performed. Purpose The purpose of this study was to identify all prospective studies reporting pseudoarthrosis rates for ACDF with plate fixation. Study design/setting This study is based on a systematic review and meta-analysis. Patient sample Studies reporting pseudoarthrosis rates in patients who received one-, two-, or three-level ACDF surgeries were included. Outcome measures Outcomes of interest included reported pseudoarthrosis events after ACDF with plate fixation. Methods We conducted a MEDLINE, SCOPUS, Web of Science, and EMBASE search for studies reporting complications for ACDF with plate fixation. We recorded pseudoarthrosis events from all included studies. A meta-analysis was performed to calculate effect summary mean values, 95% confidence intervals (CIs), Q statistics, and I2 values. Forest plots were constructed for each analysis group. Results Of the 7,130 retrieved articles, 17 met the inclusion criteria. The overall pseudoarthrosis rate was 2.6% (95% CI: 1.3–3.9). Use of autograft fusion (0.9%, 95% CI: –0.4 to 2.1) resulted in a reduced pseudoarthrosis rate compared with allograft fusion procedures (4.8%, 95% CI: 1.7–7.9). Studies were separated based on the length of follow-up: 12 to 24 and greater than 24 months. These groups reported rates of 3.1% (95% CI: 1.2–5.0) and 2.3% (95% CI: 0.1–4.4), respectively. Studies performing single-level ACDF yielded a rate of 3.7% (95% CI: 1.6–5.7). Additionally, there was a large difference in the rate of pseudoarthrosis in randomized controlled trials (4.8%, 95% CI: 2.6–7.0) versus prospective cohort studies (0.2%, 95% CI: –0.1 to 0.5), indicating that the extent of follow-up criteria affects the rate of pseudoarthrosis. Conclusions This review represents a comprehensive estimation of the actual incidence of pseudoarthrosis across a heterogeneous group of surgeons, patients, and ACDF techniques. The definition of pseudoarthrosis varied significantly within the literature. To ensure its diagnosis and prevent sequelae, standardized criteria need to be established. This investigation sets the framework for surgeons to understand the impact of surgical techniques on the rate of pseudoarthrosis.
STUDY DESIGN.A retrospective cohort analysis of prospectively collected clinical data.
OBJECTIVE.The aim of this study was to assess the effect of race on outcomes in patients undergoing elective ...laminectomy and/or fusion spine surgery.
SUMMARY OF BACKGROUND DATA.Studies that have looked at the effect of race on spine surgery outcomes have failed to take into account baseline risk factors that may influence peri-operative outcomes.
METHODS.We identified 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion, from 2006 to 2012, at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity. Pre- and intraoperative characteristics and 30-day outcomes were stratified by race. We used propensity scores to match African-American and Caucasian patients on all pre- and intraoperative factors, including by principal diagnosis leading to surgery as well as surgery performed. We used regular and conditional logistic regression to predict the effect of race on adverse postoperative outcomes in the full sample and matched sample.
RESULTS.Caucasians comprised 82% of our sample. We found no differences in the incidence of pre- and intraoperative factors when comparing Caucasian patients with all minority patients, and only minimal increased odds for prolonged length of length of hospitalization (LOS) and discharge with continued care. However, African-American patients, who comprised 39% of our minority sample, had more preoperative comorbidities than Caucasian patients. Even after eliminating all differences between pre- and intraoperative factors between Caucasian and African-American patients, African-American patients continued to have LOS that was, on average, one day longer than Caucasian patients. African-American patients also had higher odds for major complications odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1–1.6, and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8–2.8).
CONCLUSION.African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery.Level of Evidence3
IMPORTANCE: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency ...department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. OBJECTIVE: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. EVIDENCE REVIEW: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. FINDINGS: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. CONCLUSIONS AND RELEVANCE: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
OBJECTIVE Improvements in imaging technology have steadily advanced surgical approaches. Within the field of spine surgery, assistance from the O-arm Multidimensional Surgical Imaging System has been ...established to yield superior accuracy of pedicle screw insertion compared with freehand and fluoroscopic approaches. Despite this evidence, no studies have investigated the clinical relevance associated with increased accuracy. Accordingly, the objective of this study was to investigate the clinical outcomes following thoracolumbar spinal fusion associated with O-arm-assisted navigation. The authors hypothesized that increased accuracy achieved with O-arm-assisted navigation decreases the rate of reoperation secondary to reduced hardware failure and screw misplacement. METHODS A consecutive retrospective review of all patients who underwent open thoracolumbar spinal fusion at a single tertiary-care institution between December 2012 and December 2014 was conducted. Outcomes assessed included operative time, length of hospital stay, and rates of readmission and reoperation. Mixed-effects Cox proportional hazards modeling, with surgeon as a random effect, was used to investigate the association between O-arm-assisted navigation and postoperative outcomes. RESULTS Among 1208 procedures, 614 were performed with O-arm-assisted navigation, 356 using freehand techniques, and 238 using fluoroscopic guidance. The most common indication for surgery was spondylolisthesis (56.2%), and most patients underwent a posterolateral fusion only (59.4%). Although O-arm procedures involved more vertebral levels compared with the combined freehand/fluoroscopy cohort (4.79 vs 4.26 vertebral levels; p < 0.01), no significant differences in operative time were observed (4.40 vs 4.30 hours; p = 0.38). Patients who underwent an O-arm procedure experienced shorter hospital stays (4.72 vs 5.43 days; p < 0.01). O-arm-assisted navigation trended toward predicting decreased risk of spine-related readmission (0.8% vs 2.2%, risk ratio RR 0.37; p = 0.05) and overall readmissions (4.9% vs 7.4%, RR 0.66; p = 0.07). The O-arm was significantly associated with decreased risk of reoperation for hardware failure (2.9% vs 5.9%, RR 0.50; p = 0.01), screw misplacement (1.6% vs 4.2%, RR 0.39; p < 0.01), and all-cause reoperation (5.2% vs 10.9%, RR 0.48; p < 0.01). Mixed-effects Cox proportional hazards modeling revealed that O-arm-assisted navigation was a significant predictor of decreased risk of reoperation (HR 0.49; p < 0.01). The protective effect of O-arm-assisted navigation against reoperation was durable in subset analysis of procedures involving < 5 vertebral levels (HR 0.44; p = 0.01) and ≥ 5 levels (HR 0.48; p = 0.03). Further subset analysis demonstrated that O-arm-assisted navigation predicted decreased risk of reoperation among patients undergoing posterolateral fusion only (HR 0.39; p < 0.01) and anterior lumbar interbody fusion (HR 0.22; p = 0.03), but not posterior/transforaminal lumbar interbody fusion. CONCLUSIONS To the authors' knowledge, the present study is the first to investigate clinical outcomes associated with O-arm-assisted navigation following thoracolumbar spinal fusion. O-arm-assisted navigation decreased the risk of reoperation to less than half the risk associated with freehand and fluoroscopic approaches. Future randomized controlled trials to corroborate the findings of the present study are warranted.
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