Spine

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Patient Reported Outcomes in Patients Who Stop Following Up: Are They Doing Better or Worse Than the Patients That Come Back?

imageStudy Design.
Follow-up study.
Objective.
To determine whether minimally invasive lumbar spine surgery outcomes are different between those who are lost to follow-up and those who are not.
Summary of Background Data.
Lost to follow-up patients are a common source of selection bias for clinical outcomes research. Currently, there are no US based studies that evaluate the differences in outcomes of lost to follow-up patients after spine surgeries.
Methods.
A retrospective review of prospectively collected data of 289 patients who underwent minimally invasive lumbar surgery and were at least 1 year postsurgery was performed. Patients were divided into two groups: (1) lost to follow-up (LTF), defined as patients who had missed more than two consecutive follow-up visits and had not attended their 1-year follow-up appointment; and (2) not lost to follow-up. For the not-LTF cohort, patient response outcome measures (PROMs) (oswestry disability index (ODI), visual analog scale (VAS) back/leg, Short Form-12 (SF-12) Physical/Mental, PROMIS) and return to activities data were collected prospectively at each follow-up. For LTF patients, data were collected through emailed surveys or telephone interviews. PROMs and return to activities data of the two groups were compared. Sub-group analysis by type of surgery (decompression or fusion) was also performed.
Results.
For the entire cohort, independent t test analysis showed LTF patients had greater improvement in PROMIS Physical Function scores than those who were not-LTF (15.08 vs. 10.38, P = 0.026). For fusion surgeries, LTF patients showed a greater improvement in ODI (–30.94 vs. –16.23, P = 0.003) VAS back (–4.92 vs. –2.99, P = 0.044), and PROMIS-PF (16.09 vs. 10.38, P = 0.049). There were no significant differences in complication rates between LTF and not LTF patients.
Conclusion.
Patients undergoing minimally invasive lumbar surgery—in particular lumbar fusions—who are lost to follow-up and responded to subsequent email and phone interviews showed greater improvements in self-reported outcomes than those who continued to follow-up. Thus, our results suggest that a substantial subset of patients who are lost to follow-up do not fare worse than those who do follow-up. However, an opposite response cannot be excluded in those who did not respond to email and phone interviews.
Level of Evidence: 3

Feed Item Url: 
https://journals.lww.com/spinejournal/Fulltext/2020/10150/Patient_Reported_Outcomes_in_Patients_Who_Stop.13.aspx

Can We Change Health Care Costs in Patients With Complex Back Pain?: Results From a 5-year Before and After Study

imageStudy Design.
A before and after study cohort study.
Objectives.
The aim of this study was to examine changes in health care costs after multidisciplinary spine care in patients with complex chronic back pain (CBP), to analyze the predictive value of patient and disease characteristics on health care costs, and to study the potential impact of biases concerning the use of real world data.
Summary of Background Data.
Due to high direct and indirect societal costs of back pain there is a need for interventions that can assist in reducing the economic burden on patients and society.
Methods.
All patients referred to a university-based spine center insured at a major health care insurer in the Netherlands were invited. Personal and disease-related data were collected at baseline. Health care costs were retrieved from the health care insurer from 2 years before to 2 years after intervention. Repeated measures analysis of variances were calculated to study changes in health care costs after intervention. Multivariable regression analyses and cluster robust fixed effect models were applied to predict characteristics on health care costs. To study regression to the mean, a fixed effect model was calculated comparing 2 years before and 2 years post-intervention.
Results.
In total 428,158 declarations during 4.6 years were filed by 997 participants (128,666 considered CBP-related). CBP-related costs significantly increased during the intervention period and reduced 2 years after the intervention. Total health care costs kept rising. The intervention was associated with a 21% to 34% (P < 0.01) reduction in costs depending on the model used. Reduction in costs was related to being male and lower body mass index.
Conclusion.
This study suggests that reduction in CBP-related health care utilization in patients with complex CBP can be achieved after a multidisciplinary spine intervention. The results are robust to controlling for background characteristics and are unlikely to be fully driven by regression to the mean.
Level of Evidence: 4

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https://journals.lww.com/spinejournal/Fulltext/2020/10150/Can_We_Change_Health_Care_Costs_in_Patients_With.14.aspx

Outcomes of Minimally Invasive versus Open Surgery for Intermediate to High-grade Spondylolisthesis: A 10-Year Retrospective, Multicenter Experience

imageStudy Design.
Retrospective cohort study.
Objective.
The primary objective of our study was to evaluate the surgical outcomes and complications of minimally invasive surgery (MIS) versus open surgery in the management of intermediate to high grade spondylolisthesis, and secondarily to compare the outcomes following MIS in-situ fusion versus MIS reduction and open in-situ fusion versus open reduction subgroups.
Summary of Background Data.
High-grade spondylolisthesis is a relatively rare spine pathology with unknown prevalence. The optimal management and long-term prognosis of high-grade spondylolisthesis remain controversial.
Methods.
A multicenter, retrospective cohort study of adult patients who were surgically treated for grade II or higher lumbar or lumbosacral spondylolisthesis from January 2008 until February 2019, was conducted.
Results.
A total of 57 patients were included in this study. Forty cases were treated with open surgery and 17 with MIS. Specifically, seven patients underwent MIS in-situ fusion, 11 patients open in-situ fusion, an additional 10 patients underwent MIS reduction, and 29 had open reduction. Patients who underwent open surgery had significantly better pain relief at short-term follow-up with no statistically significant difference in the rate of complications (25% vs. 35.2%, P = 0.44), as compared with MIS. The most common complications were related to instrumentation (17.7%), followed by neurological complications (14.5%), wound infection/dehiscence (6.5%), and post laminectomy syndrome (1.6%). The average follow-up time was 9.1 ± 6.2 months. In a subgroup comparison, the complication rate in the open in-situ fusion (36.3%) versus open reduction (20.6%) subgroup was non-significant (P = 0.42). However, complication rate in the MIS reduction group (55%) was significantly higher than MIS in-situ fusion (P = 0.03).
Conclusion.
MIS reduction is associated with a higher rate of complications in the management of grade II or higher lumbar or lumbosacral spondylolisthesis. The management of this complex pathology may be better addressed via traditional open surgery.
Level of Evidence: 3

Feed Item Url: 
https://journals.lww.com/spinejournal/Fulltext/2020/10150/Outcomes_of_Minimally_Invasive_versus_Open_Surgery.16.aspx

“Prayer of the Monkey”

imageNo abstract available

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https://journals.lww.com/spinejournal/Fulltext/2020/10150/_Prayer_of_the_Monkey_.1.aspx

Comparison of Clinical and Radiographic Outcomes of Laminoplasty, Anterior Decompression With Fusion, and Posterior Decompression With Fusion for Degenerative Cervical Myelopathy: A Prospective Multicenter Study

imageStudy Design.
Prospective multicenter study.
Objective.
The aim of this study was to compare the clinical and radiographic results of laminoplasty (LAMP), anterior decompression with fusion (ADF), and posterior decompression with fusion (PDF) for degenerative cervical myelopathy (DCM).
Summary of Background Data.
Although ADF, LAMP, and PDF have been performed for DCM, little is known about the difference in impact of these surgical treatments on clinical and radiographic outcomes.
Methods.
We prospectively enrolled patients who were scheduled for surgery for DCM and compared the clinical and radiographic results of ADF, LAMP, and PDF.
Results.
In total, 171 patients completed the 1-year follow-up. Regarding clinical outcomes, the Japanese Orthopedic Association score for the assessment of cervical myelopathy (C-JOA score), European Quality of Life-5 Dimensions (EQ-5D), and Neck Disability Index (NDI) scores improved in all groups postoperatively. However, no significant differences were found in C-JOA, EQ-5D, and NDI scores and recovery rate among the groups. Regarding radiographic parameters, although the operation had no effect on cervical lordosis (CL) and the C2–7 sagittal vertical axis (SVA) in the ADF group, they worsened in the LAMP and PDF group. Although there were no significant differences in any preoperative radiographic parameters within the ADF and LAMP group, CL was significantly lower and the C2–7 SVA was significantly higher in the nonrecovery group within the PDF group. Logistic regression analysis showed that preoperative lower CL was an independent risk factor for poor recovery in the PDF group.
Conclusion.
Although groups showed no significant differences in clinical outcomes, cervical alignment worsened after surgery in the LAMP and PDF groups. Within the PDF group, lower CL was an independent risk factor for poor recovery. Therefore, the indications for PDF in DCM patients with preoperative kyphotic alignment should be carefully considered.
Level of Evidence: 3

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https://journals.lww.com/spinejournal/Fulltext/2020/10150/Comparison_of_Clinical_and_Radiographic_Outcomes.17.aspx

The Intelligent Automated Pressure-Adjustable Orthosis for Patients With Adolescent Idiopathic Scoliosis: A Bi-Center Randomized Controlled Trial

imageStudy Design.
Randomized controlled trial.
Objective.
To compare the effectiveness of the automated pressure-adjustable orthosis (PO) and conventional orthosis (CO) for treatment of adolescent idiopathic scoliosis (AIS).
Summary of Background Data.
Orthosis wearing quality may influence its effectiveness for AIS. An automated PO aimed to provide a more optimized and consistent biomechanical environment. Clinical evaluation was conducted to study the effectiveness of this innovative orthosis.
Methods.
Patients with AIS who met the criteria (Age 10–14, Cobb 20°–40°, and Risser sign 0–2) were recruited from two clinics and randomly assigned to the PO and CO groups. Compliance sensors were embedded in both groups, while the PO group was set to adjust the interfacial pressure as prescribed automatically. Clinical assessments (radiology and quality of life, QoL) were conducted at the baseline, immediate after orthosis fitting and 1-year follow-up. Orthosis wearing compliance was tracked using thermo and pressure sensors.
Results.
Twenty-four patients were enrolled with one drop-out (PO, n = 11; CO, n = 12). Significant immediate in-orthosis correction was observed in the PO (11.0° ± 6.5°, 42.0%, P < 0.001) and CO (10.3° ± 5.3°, 37.6%, P < 0.001) groups. After 1 year, no patient with PO progressed while two with CO had progression more than 5°. The mean daily wearing duration was 1.1 hours longer in the PO group as compared with the CO group (15.4 ± 4.5 vs. 14.3 ± 3.8 h). Moreover, the wearing quality within the targeted pressure was 33.9% higher in the PO group (56.5 ± 16.5% vs. 23.1 ± 12.1%, P < 0.001). No significant difference in the QoL results was observed between two groups nor within both groups during the study period.
Conclusion.
This study showed that the automated PO could enhance wearing quality when compared with the CO, thus offering a better biomechanical corrective effect in the study period without adverse effect on the patients’ wearing quantity and QoL.
Level of Evidence: 1

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https://journals.lww.com/spinejournal/Fulltext/2020/10150/The_Intelligent_Automated_Pressure_Adjustable.2.aspx

Trends in Reoperation for Surgical Site Infection After Spinal Surgery With Instrumentation in a Multicenter Study

imageStudy Design.
A multicenter retrospective analysis of a prospectively maintained database.
Objective.
To examine the characteristics of reoperation for surgical site infection (SSI) after spinal instrumentation surgery, including the efficacy of treatment for SSI and instrumentation retention.
Summary of Background Data.
Aging of the population and advances in surgical techniques have increased the demand for spinal surgery in elderly patients. Treatment of SSI after this surgery has the main goals of eliminating infection and retaining instrumentation.
Methods.
The subjects were 16,707 patients who underwent spine surgery with instrumentation in 11 hospitals affiliated with the Nagoya Spine Group from 2004 to 2015. Details of those requiring reoperations for SSI were obtained from surgical records at each hospital.
Results.
There were significant increases in the mean age at the time of surgery (54.6–63.7 years) and the number of instrumentation surgeries (726–1977) from 2004 to 2015. The incidence of reoperation for SSI varied from 0.9% to 1.8%, with a decreasing trend over time. Reoperation for SSI was performed in 206 cases (115 men, 91 women; mean age 63.2 years). The average number of reoperations (1.4 vs. 2.3, P < 0.05), time from SSI to first reoperation (4.3 vs. 9.5 days, P < 0.05), and the methicillin-resistant Staphylococcus identification rate (20% vs. 37%, P < 0.01) were all significantly lower in cases with instrumentation retention (n = 145) compared to those with instrumentation removal (n = 61).
Conclusion.
There were marked trends of aging of patients and an increase in operations over the study period; however, the incidences of reoperation and instrumentation removal due to SSI significantly decreased over the same period. Rapid debridement after SSI diagnosis may have contributed to instrumentation retention. These results can serve as a guide for developing strategies for SSI treatment and for improved planning of spine surgery in an aging society.
Level of Evidence: 3

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https://journals.lww.com/spinejournal/Fulltext/2020/10150/Trends_in_Reoperation_for_Surgical_Site_Infection.18.aspx

Increasing Fusion Rate Between 1 and 2 Years After Instrumented Posterolateral Spinal Fusion and the Role of Bone Grafting

imageStudy Design.
Two-year clinical and radiographic follow-up of a double-blind, multicenter, randomized, intra-patient controlled, non-inferiority trial comparing a bone graft substitute (AttraX® Putty) with autograft in instrumented posterolateral fusion (PLF) surgery.
Objectives.
The aim of this study was to compare PLF rates between 1 and 2 years of follow-up and between graft types, and to explore the role of bone grafting based on the location of the PLF mass.
Summary of Background Data.
There are indications that bony fusion proceeds over time, but it is unknown to what extent this can be related to bone grafting.
Methods.
A total of 100 adult patients underwent a primary, single- or multilevel, thoracolumbar PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX® Putty was disclosed. The contralateral posterolateral gutters were grafted with autograft. At 1-year follow-up, and in case of no fusion at 2 years, the fusion status of both sides of each segment was blindly assessed on CT scans. Intertransverse and facet fusion were scored separately. Difference in fusion rates after 1 and 2 years and between grafts were analyzed with a Generalized Estimating Equations (GEE) model (P < 0.05).
Results.
The 2-year PLF rate (66 patients) was 70% at the AttraX® Putty and 68% at the autograft side, compared to 55% and 52% after 1 year (87 patients). GEE analysis demonstrated a significant increase for both conditions (odds ratio 2.0, 95% confidence interval 1.5–2.7, P < 0.001), but no difference between the grafts (P = 0.595). Ongoing bone formation was only observed between the facet joints.
Conclusion.
This intra-patient controlled trial demonstrated a significant increase in PLF rate between 1 and 2 years after instrumented thoracolumbar fusion, but no difference between AttraX® Putty and autograft. Based on the location of the PLF mass, this increase is most likely the result of immobilization instead of grafting.
Level of Evidence: 1

Feed Item Url: 
https://journals.lww.com/spinejournal/Fulltext/2020/10150/Increasing_Fusion_Rate_Between_1_and_2_Years_After.3.aspx

Safety Evaluation of Biportal Endoscopic Lumbar Discectomy: Assessment of Cervical Epidural Pressure During Surgery

imageStudy Design.
A prospective study.
Objective.
To evaluate the change in cervical epidural pressure (CEP) during biportal endoscopic lumbar discectomy (BELD).
Summary of Background Data.
In percutaneous uniportal endoscopic lumbar discectomy, irrigation fluid (IF) introduced into the spinal canal during surgery can compress the thecal sac, and act as a potential risk for neurological complications by disturbing cerebrospinal fluid (CSF) circulation and increasing intracranial pressure.
Methods.
Thirty consecutive patients, who underwent BELD, which was performed under automated pump system, an infusion pressure of 30 mmHg were enrolled. The change in CEP on C7–T1 level was measured. CEP was measured in each of the five phases of the procedure (1st phase—making surgical portals; 2nd phase—creating a workspace; 3rd phase—performing neural decompression and discectomy; 4th phase—factitious increase of pressure by clogging the outflow; 5th phase—dismission from fluid irrigation system). Neurological complications and independent risk factors were evaluated.
Results.
In the final 27 patients, changes in CEP during surgery were similar. The baseline CEP was 14.8 ± 2.8 mmHg, and the mean CEP in the 3rd phase 18.8 ± 5.1 mmHg was not significantly higher. In the 4th phase, however, the CEPs rose with linear correlation as the pressure increased. In the 5th phase, the elevated CEP returned to baseline in 2.5 ± 5.6 minutes. No patient had neurological complications. No statistically significant risk factors were observed.
Conclusion.
In BELD, which is performed to allow continuous lavage with infusion pressure set to 30 mmHg, CEP does not increase beyond the physiological range. Therefore, BELD may be considered as a potentially safe technique.
Level of Evidence: 4

Feed Item Url: 
https://journals.lww.com/spinejournal/Fulltext/2020/10150/Safety_Evaluation_of_Biportal_Endoscopic_Lumbar.19.aspx

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