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Predictive Value of Comprehensive Geriatric Assessment on Early Postoperative Complications Following Lumbar Spinal Stenosis Surgery: A Prospective Cohort Study

imageStudy Design.
Prospective cohort study.
Objective.
The aim of this study was to evaluate the predictive value of comprehensive geriatric assessment (CGA) for early postoperative complications in elderly patients (aged 65 years or older) following lumbar spinal stenosis surgery.
Summary of Background Data.
CGA is a multidisciplinary evaluation modality proven to be effective in various fields of geriatrics. However, limited evidence exists on the effectiveness of CGA in lumbar spinal stenosis patients in the literature.
Methods.
We prospectively enrolled consecutive patients who were at least 65 years’ old and were scheduled to undergo elective surgery for lumbar spinal stenosis. One day before the operation, multidomain CGA was performed on the patient's functional status, comorbidities, nutrition, cognition, and psychological status. Patients with deficits in three or more CGA domains were defined as frail. The occurrence of postoperative complications (Clavien and Dindo grade 2 or higher) within 30 days after the surgery was assessed as the outcome. The predictive value of CGA was evaluated using crosstab and logistic regression analysis and compared to that of other risk stratification systems, including modified Frailty Index-5, -11, and American Society of Anesthesiologists Physical Classification System.
Results.
A total of 261 patients were included in the study, and 25 (9.6%) patients were assigned to the “frail” group. There were 27 (10.3%) patients with a postoperative complication (general: n = 20, 7.7%, surgical: n = 7, 2.7%) within postoperative 30 days. Patients with a complication showed significantly more deficits on preoperative CGA than those without complications (P = 0.004). On multivariate logistic regression analysis, frailty based on CGA (odds ratio = 3.51, P = 0.031) and the modified Frailty Index-11 (odds ratio = 3.13, P = 0.038) were associated with the occurrence of general complications.
Conclusion.
Frailty based on CGA was significantly associated with early general complications following surgery for lumbar spinal stenosis in patients older than 65 years.
Level of Evidence: 2

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Predictive_Value_of_Comprehensive_Geriatric.10.aspx

Single-level Posterolateral Fusion (PLF) Alone and Posterior Interbody Fusion (PLIF/TLIF) Alone Lead to a Decreased Risk of Short-term Complications Compared to Combined PLF With PLIF/TLIF Procedures: A Matched Analysis

imageStudy Design.
Retrospective review of a database cohort.
Objective.
To compare short-term outcome measures and complications between single-level posterolateral fusion (PLF), single-level posterior interbody fusion (PLIF/TLIF), and combined single-level PLF+PLIF/TLIF.
Summary of Background Data.
Both PLF and interbody fusion are well-established procedures for degenerative spinal disease. However, there is lack of consensus as to the ideal surgical approach for specific applications. Additionally, the difference in risk of complications with traditional PLF, interbody fusion with posterior approach, and circumferential fusion is still contested.
Methods.
The ACS NSQIP database was used to identify 24,228 patients who underwent either a single-level PLF, single-level PLIF/TLIF, or combined single-level PLF+PLIF/TLIF between 2014 and 2017. To control for potential confounding variables, exact matching was used to pair individuals from each treatment group based on several factors, including sex, age, body mass index, various comorbidities, and American Society of Anesthesiologists classification. After appropriate matching, the rate of various short-term outcome measures and complications were compared between the three treatment groups.
Results.
After exact matching, 13,251 patients were included in the final analysis. The rates of non-home discharge, overall surgical complications, and bleeding requiring transfusion were significantly lower in the PLF group and PLIF/TLIF group relative to the PLF+PLIF/TLIF group (P < 0.001 for all comparisons). The rate of deep venous thrombosis was lower in the PLIF/TLIF group relative to the PLF group (P = 0.006). There were no significant differences in other medical complications, unplanned readmission, reoperation, or return to the OR between any of the treatment groups.
Conclusions.
The combination of single-level PLF+PLIF/TLIF is associated with higher rates of short-term complications relative to either single-level PLF or PLIF/TLIF alone. The associated risks of this therapy should be considered when considering surgical management for lumbar disease.
Level of Evidence: 3.

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Single_level_Posterolateral_Fusion__PLF__Alone_and.11.aspx

Spinal Osteoarthritis Is Associated With Stature Loss Independently of Incident Vertebral Fracture in Postmenopausal Women

imageStudy Design.
Retrospective observational study from the Nagano Cohort Study.
Objective.
Clarify the association between spinal osteoarthritis and loss of stature in postmenopausal women.
Summary of Background Data.
Loss of stature with aging is known to deteriorate health-related quality of life and has been implicated with increased mortality. Although the association of vertebral fracture with height loss has been well documented, the relationship between stature loss and spinal osteoarthritis remains unclear.
Methods.
We retrospectively investigated Japanese postmenopausal women recruited from the Nagano Cohort Study. The participants were outpatients at a primary care institute in Nagano prefecture, Japan. A total of 977 postmenopausal patients (mean age: 65.8 yr) completed a minimum of 1 year of follow-up, with an average observation period of 7.6 years. Quartile analysis on the prevalence of spinal osteoarthritis and occurrence of incident fracture was performed based on the rate of stature change per year (Δ cm/yr). Multiple regression analysis was also conducted to identify the determinants of stature change.
Results.
The lower quartiles of stature change rate (i.e., more rapid stature loss) displayed a significantly higher prevalence of spinal osteoarthritis (P < 0.001) and incident vertebral fracture (P < 0.001). A statistically significant independent negative association for spinal osteoarthritis prevalence with change in stature was revealed by multiple regression analysis after adjusting for confounders including incident vertebral fracture. The partial regression coefficient for spinal osteoarthritis was −0.18 (95% confidence interval −0.33 to −0.03; P = 0.016).
Conclusion.
This study demonstrated an independent association of spinal osteoarthritis with stature loss in postmenopausal women. Adequate understanding of this relationship and appropriate treatment approaches will help improve health-related quality of life in elderly patients.
Level of Evidence: 3

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Spinal_Osteoarthritis_Is_Associated_With_Stature.12.aspx

Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis

imageStudy Design.
Systematic with meta-analysis
Objectives.
The aim of this study was to investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection in reducing leg pain and disability in patients with sciatica.
Summary of Background Data.
Conservative treatments, including pharmacological and nonpharmacological treatments, are typically the first treatment options for sciatica but the evidence to support their use is limited. The overall quality of evidence found by previous systematic reviews varies between moderate and high, which suggests that future trials may change the conclusions. New placebo-controlled randomized trials have been published recently which highlights the importance of an updated systematic review.
Methods.
The searches were performed without language restrictions in the following databases from 2012 to 25 September 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PubMed, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and trial registers. We included placebo-controlled randomized trials investigating epidural corticosteroid injections in patients with sciatica. The primary outcomes were leg pain intensity and disability. The secondary outcomes were adverse events, overall pain, and back pain intensity. We grouped similar trials according to outcome measures and their respective follow-up time points. Short-term follow-up (>2 weeks but ≤3 months) was considered the primary follow-up time point due to the expected mechanism of action of epidural corticosteroid injection. Weighted mean differences (MDs) and risk ratios (RRs) with their respective 95% confidence intervals (CIs) were estimated. We assessed the overall quality of evidence using the GRADE approach and conducted the analyses using random effects.
Results.
We included 25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD −4.93, 95% CI −8.77 to −1.09 on a 0–100 scale), short-term disability (MD −4.18, 95% CI: −6.04 to −2.17 on a 0–100 scale) and may be slightly more effective in reducing short-term overall pain (MD −9.35, 95% CI −14.05 to −4.65 on a 0–100 scale). There were mostly minor adverse events (i.e., without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR 1.14, 95% CI: 0.91–1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency.
Conclusion.
A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence.
Level of Evidence: 1

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Epidural_Corticosteroid_Injections_for_Sciatica_.13.aspx

Postoperative Distal Coronal Decompensation After Fusion to L3 for Adolescent Idiopathic Scoliosis Is Affected by Sagittal Pelvic Parameters

imageStudy Design.
Retrospective study.
Objective.
To identify on early postoperative radiographs the risk factors for late distal decompensation in adolescent idiopathic scoliosis (AIS) patients undergoing posterior fusion surgery to L3.
Summary of Background Data.
Sparing distal fusion levels in AIS surgery is considered beneficial for postoperative mobility and outcomes; nonetheless, late distal decompensation is of concern. L3 is often advocated as lower instrumented vertebra in posterior fusion, but progressive angulation of the L3/4 disc is commonly observed.
Methods.
A retrospective analysis was conducted on 78 AIS patients who underwent posterior fusion to L3 from 2007 to 2014. Patients’ demographic data, early and 2-year postoperative standing radiographs by biplanar imaging system were investigated. Late decompensation was defined as progressive increase of L3–4 disc wedging angle at 2-year follow-up. Coronal, sagittal, and rotational radiographic parameters were compared between those with and without decompensation. SRS-30 scores were reviewed.
Results.
Mean age was 14.5-year, and fusion levels averaged 12.0 (range: 6–15); 43 out of 78 patients (55%) experienced progressive L3-4 disc wedging, with 6 showing wedging >5°. L3 translation from the central sacral vertical line (13.9 vs. 11.1 mm, P = 0.13) and increased pelvic tilt (13.3° vs. 8.6°, P = 0.06) on the early postoperative radiograph were associated with increased L3-4 disc wedging. Multivariate analysis revealed that larger pelvic tilt was a significant risk factor for decompensation (odds ratio = 1.1 per 1°, 95% confidence interval: 1.0–1.1, P = 0.04). SRS-30 scores did not differ significantly between the two groups (4.0 vs. 4.1, P = 0.44).
Conclusions.
Pelvic retroversion and increased translation of L3 from the central sacral line on the early postoperative radiograph were associated with late L3-4 disc wedging in AIS fusions to L3. Careful surgical planning and correction of sagittal alignment are imperative to ensure the long-term outcomes.
Level of Evidence: 4

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Postoperative_Distal_Coronal_Decompensation_After.14.aspx

The Noninvasive Diagnostic Value of MRN for CIDP: A Research from Qualitative to Quantitative

imageStudy Design.
We examined the chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients and non-CIDP patients who have similar symptoms and difficult to differential diagnosis with CIDP by magnetic resonance neurography to find the difference among them.
Objective.
To investigate the differential diagnostic value of magnetic resonance neurography (MRN) for CIDP and other peripheral neuropathies.
Summary of Background Data.
Thirty-two consecutive patients with CIDP and 22 non-CIDP patients with symptoms similar to CIDP and difficult to be discriminate were recruited and imaged as a control group between May 2017 and May 2019.
Methods.
In this prospective study, the brachial plexus and lumbosacral plexus of 32 CIDP patients and 22 non-CIDP patients were examined by MRN. The clinical features and the nerve roots cross-sectional area (CSA) of the brachial plexus and lumbosacral plexus were measured.
Results.
The CSA of nerve roots of CIDP, Charcot-Marie-Tooth disease type-1 and polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes syndrome patients were all shown extensive by MRN. The sensitivity of MRN in diagnosing CIDP was 81.25% (26/32), the specificity was 68.18% (15/22), the positive predictive value was 78.79% (26/33), the negative predictive value was 71.43% (15/21), the accuracy was 75.93% (40/54), the misdiagnosis rate was 24.07% (13/54), and the kappa value was 0.498. Receiver operating characteristic analysis showed higher diagnostic accuracy for CIDP with the CSA of the lumbosacral plexus (area under the curve [AUC] = 0.762) and that of the brachial plexus (AUC = 0.762), and the combined of both examinations did not improve the diagnostic efficacy compared with either (AUC = 0.769).
Conclusions.
The nerve roots of CIDP, Charcot-Marie-Tooth disease type-1, and polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes syndrome were difficult to distinguish by MRN. Atypical CIDP patients had less nerve root injury compared with typical CIDP patients. MRN of either the brachial plexus or the lumbosacral plexus had a high diagnostic accuracy for CIDP, and it is not necessary to perform both parts of the examination.
Level of Evidence: 2

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/The_Noninvasive_Diagnostic_Value_of_MRN_for_CIDP_.15.aspx

Radiological Risk Factors for Neurological Deficits After Traumatic Mid and Low Lumbar Fractures

imageStudy Design.
Retrospective study.
Objective.
We identified radiological risk factors for neurological deficits in mid and low lumbar spinal fractures.
Summary of Background Data.
Although numerous studies have focused on radiological risk factors for neurological deficits in spinal cord injury or thoracolumbar junction area fractures, few have examined mid and low lumbar fractures at the cauda equina level.
Methods.
We retrospectively reviewed 71 consecutive patients who suffered acute traumatic mid and low lumbar fractures (L2–L5) corresponding to the cauda equina level, as confirmed on magnetic resonance imaging. We defined a neurological deficit as present if the patient had any sensory or motor deficit in the lower extremity or autonomic system at the initial assessment. Various computed tomography parameters of canal stenosis, vertebral body compression, sagittal alignment, interpedicular distance, and presence of vertical laminar fractures were analyzed as independent risk factors to predict neurological deficits using multivariate logistic regression analyses.
Results.
At the initial assessment, 31 patients had neurological deficits. Fracture level, AO fracture type, canal encroachment ratio, vertebral compression ratio, interpedicular distance ratio, and presence of a vertical laminar fracture were significantly associated with the presence of neurological deficits (all P < 0.05). Multivariate logistic regression identified fracture level, canal encroachment ratio (adjusted odds ratio [aOR] 1.072, 95% confidence interval [CI] 1.018–1.129), and vertebral compression ratio (aOR 0.884, 95% CI 0.788–0.992) as independent predictors of a neurological deficit. Receiver operating characteristic curve analyses revealed that only the canal encroachment ratio had good discriminatory ability (area under the curve 0.874, 95% CI 0.791–0.957), and the optimal cutoff was 47% (canal diameter 6.6 mm) with 90.3% sensitivity and 80% specificity.
Conclusion.
The canal encroachment ratio was most strongly associated with neurological deficits in traumatic mid and low lumbar fractures, with an optimal cutoff of 47%.
Level of Evidence: 4

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/Radiological_Risk_Factors_for_Neurological.16.aspx

“Trek from Chopta to Tunganath”

imageNo abstract available

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https://journals.lww.com/spinejournal/Fulltext/2020/11010/_Trek_from_Chopta_to_Tunganath_.1.aspx

Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis

imageStudy Design.
Longitudinal analysis of prospectively collected data.
Objective.
Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS).
Summary of Background Data.
LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection.
Methods.
We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability).
Results.
Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination.
Conclusion.
Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS.
Level of Evidence: 2

Feed Item Url: 
https://journals.lww.com/spinejournal/Fulltext/2020/11010/Preoperative_Factors_Predict_Postoperative.17.aspx

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