Adjacent segment degeneration after lumbar spinal fusion compared with motion-preservation procedures: a meta-analysis

Purpose

This meta-analysis aimed to evaluate the efficacy of motion-preservation procedures to prevent the adjacent segment degeneration (ASDeg) or adjacent segment disease (ASDis) compared with fusion in lumbar spine.

Methods

PubMed, Embase and the Cochrane Library were comprehensively searched and a meta-analysis was performed of all randomized controlled trials and well designed prospective or retrospective comparative cohort studies assessing the lumbar fusion and motion-preservation procedures. We compared the ASDeg and ASDis rate, reoperation rate, operation time, blood loss, length of hospital stay, visual analogue scale (VAS) and oswestry disability index (ODI) improvement of the two procedures.

Results

A total of 15 studies consisting of 1474 patients were included in this study. The meta-analysis indicated that the prevalence of ASDeg, ASDis and reoperation rate on the adjacent level were lower in motion-preservation procedures group than in the fusion group (P = 0.001; P = 0.0004; P < 0.0001). Moreover, shorter length of hospital stay was found in motion-preservation procedures group (P < 0.0001). No difference was found in terms of operation time (P = 0.57), blood loss (P = 0.27), VAS (P = 0.76) and ODI improvement (P = 0.71) between the two groups.

Conclusions

The present evidences indicated that the motion-preservation procedures had an advantage on reducing the prevalence of ASDeg, ASDis and the reoperation rate due to the adjacent segment degeneration compared with the lumbar fusion. And the clinical outcomes of the two procedures are similar.

     

颈椎椎间盘置换术与前路颈椎椎间盘切除融合术对相邻节段病变参数影响的荟萃分析

目的对颈椎椎间盘置换术(CDA)和前路颈椎椎间盘切除融合术(ACDF)在相邻节段退行性变(ASDeg)、相邻节段疾病(ASDis)、相邻节段再手术(ASR)及相邻节段活动度(ROM)的影响方面进行荟萃分析。方法检索PubMed、Medline、EMbase及Cochrane图书馆等数据库,检索文献为2018年6月前发表的CDA与ACDF的随机对照研究(RCT),采用Cochrane系统评价指南的评分量表对纳入文献的随机方法和偏倚进行评估。主要提取的数据包括随访时间,ASDeg、ASDis和ASR发生率,相邻节段ROM。同时采用亚组分析和敏感性分析研究其高异质性。结果共33篇RCT文献纳入研究。CDA组ASR发生率明显低于ACDF组,差异有统计学意义(P<0.05);以随访时间进行亚组分析显示,随着随访时间延长,CDA组ASR发生率下降的优势增加。2年内2组的ASDeg发生率差异无统计学意义,2年后CDA组ASDeg发生率明显低于ACDF组,差异有统计学意义(P<0.05)。2组的ASDis发生率差异无统计学意义。CDA组相邻节段ROM低于ACDF组,但差异无统计学意义。结论相较于ACDF,CDA可降低ASDeg和ASR发生率,但在ASDis发生率和相邻节段ROM方面二者差异无统计学意义。     

腰椎融合术后邻近节段退化的系统回顾分析

目的探讨腰椎融合术导致融合邻近节段退化(ASDet)发生的概率、发病机制及危险因素。方法通过计算机检索和人工检索,对近30年来国内外发表的关于腰椎融合术导致邻近节段退化的文献进行系统回顾。结果共搜索到301篇相关文献,筛选出30篇符合入选标准的文献。本研究发现ASDet发病率波动在6.3%～100%,邻近节段退变(ASDeg)发病率波动范围8%～100%,邻近节段疾病(ASDis)发病率波动范围6.3%～27.4%。ASDeg平均发病率高于ASDis,P=6.751×10-7(P<0.05)。多种影响因素参与ASDet的发生。结论 ASDet、ASDeg、ASDis发病率差异较大。目前ASDet发生的机制仍不明,绝大多数学者认为与手术引起的邻近节段生物力学机制改变有关。年龄大于60岁、使用内固定器械、损伤上方小关节、改变腰椎前凸和骶倾角、破坏腰椎后方组织结构、已绝经妇女是邻近节段退化性疾病发生的危险因素。然而长节段融合是否导致ASDet的发病率增高还有待进一步研究。     

The change of adjacent segment after cervical disc arthroplasty compared with anterior cervical discectomy and fusion: a meta-analysis of randomized controlled trials

Background Context

Many meta-analyses have been performed to study the efficacy of cervical disc arthroplasty (CDA) compared with anterior cervical discectomy and fusion (ACDF); however, there are few data referring to adjacent segment within these meta-analyses, or investigators are unable to arrive at the same conclusion in the few meta-analyses about adjacent segment. With the increased concerns surrounding adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after anterior cervical surgery, it is necessary to perform a comprehensive meta-analysis to analyze adjacent segment parameters.

Risk factors for reoperation after lumbar total disc replacement at short-, mid-, and long-term follow-up

BACKGROUND CONTEXTThe reoperation rate following TDR (Total Disc replacement) has been established at short- and mid-term time points through the Food and Drug Administration Investigational Device Exemption (FDA IDE) trials. However, these trials include highly selected centers and surgeons with strict governance of indications. The utilization of TDR throughout the community needs further analysis.PURPOSETo identify the risk factors for lumbar spine reoperation in patients undergoing lumbar total disc replacement (TDR) at short-, mid-, and long-term follow-up.STUDY DESIGN/SETTINGThis study is a multi-center retrospective cohort study utilizing the New York Statewide Planning and Research Cooperative System database.PATIENT SAMPLEWe identified 1,368 patients who underwent an elective primary lumbar TDR in New York State between January 1, 2005 and September 30, 2013.OUTCOME MEASURESThe primary functional outcome of interest was lumbar reoperation, specifically the evaluation of independent risk factors for lumbar reoperation at a minimum of 2 years, with sub-analyses performed at 5 and ten years.METHODSInternational Classification of Diseases, Ninth revision codes were utilized to identify patients undergoing a primary lumbar TDR. We excluded patients with primary/revision lumbar fusion procedures and revision disc replacement procedures. Hospital academic status was determined by the Accreditation Council for Graduate Medical Education. Unique encrypted patient identifiers allowed for longitudinal follow-up for reoperation. Logistic regression models compared reoperation and no-reoperation cohorts, and were performed on sub-analyses for significant univariate predictors of reoperation.RESULTSBetween January 2005 and September 2013, 1368 patients underwent a primary lumbar TDR. Reoperation occurred in 8.8% by 2 years, 15.8% by 5 years, and 19.5% by ten years. Diabetics were more likely to have reoperations (7.5% vs 3.8%, p=.013). Teaching hospitals experienced a decreased reoperation rate compared to nonteaching hospitals at 2-year (5.0% vs 10.5%, p=.002), 5-year (10.7% vs 17.9%, p=.002) and 10-year (11.7% vs 21.9%, p=.045) follow-up. Lumbar fusion was the most common reoperation (14.2%).CONCLUSIONWe identified an 8.8% reoperation rate after inpatient lumbar TDR at 2-years, 15.8% at 5-years, and 19.5% at 10-years. When stratifying by teaching status, reoperation rates at teaching centers align with those reported in FDA IDE studies. Diabetes was the only patient factor influencing reoperation rate. There is a growing consensus that lumbar TDR is a durable and appropriate surgical option for lumbar degenerative disc disease. Proper indications are crucial to obtaining good outcomes with lumbar TDR.     

Less-invasive decompression procedures can reduce risk of reoperation for lumbar spinal stenosis with diffuse idiopathic skeletal hyperostosis extended to the lumbar segment: analysis of two retrospective cohorts

Purpose

Clinical outcomes after decompression procedures are reportedly worse for lumbar spinal stenosis (LSS) with diffuse idiopathic skeletal hyperostosis (DISH), especially DISH extended to the lumbar segment (L-DISH). However, no studies have compared the effect of less-invasive surgery versus conventional decompression techniques for LSS with DISH. The purpose of this study was to compare the long-term risk of reoperation after decompression surgery focusing on LSS with L-DISH.

Methods

This study compared open procedure cohort (open conventional fenestration) and less-invasive procedure cohort (bilateral decompression via a unilateral approach) with ≥ 5 years of follow-up. After stratified analysis by L-DISH, patients with L-DISH were propensity score-matched by age and sex.

Results

There were 57 patients with L-DISH among 489 patients in the open procedure cohort and 41 patients with L-DISH among 297 patients in the less-invasive procedure cohort. The reoperation rates in L-DISH were higher in the open than less-invasive procedure cohort for overall reoperations (25% and 7%, p = 0.026) and reoperations at index levels (18% and 5%, p = 0.059). Propensity score-matched analysis in L-DISH demonstrated that open procedures were significantly associated with increased overall reoperations (hazard ratio [HR], 6.18; 95% confidence interval [CI], 1.37–27.93) and reoperations at index levels (HR, 4.80; 95% CI, 1.04–22.23); there was no difference in reoperation at other lumbar levels.

Conclusions

Less-invasive procedures had a lower risk of reoperation, especially at index levels for LSS with L-DISH. Preserving midline-lumbar posterior elements could be desirable as a decompression procedure for LSS with L-DISH.

     

Should adjacent asymptomatic lumbar disc herniation be simultaneously rectified? A retrospective cohort study of 371 cases that received an open fusion or endoscopic discectomy only on symptomatic segments

BACKGROUND CONTEXTIn the treatment of multiple disc herniations, the decision of whether to include the presumed asymptomatic lumbar disc herniation (asLDH) at adjacent segments remains uncertain. On the one hand, the untouched asLDH might soon become symptomatic and require treatment. On the other hand, additional surgery involving more segments will introduce greater risk, complications, and cost.PURPOSETo investigate the prognosis of untreated asLDH after open fusion or percutaneous endoscopic lumbar discectomy (PELD) on symptomatic lumbar disc herniation (LDHs) in patients.STUDY DESIGNThis is a retrospective cohort study.PATIENT SAMPLEA total of 371 patients with multiple disc herniations who underwent open discectomy and fusion or PELD only for symptomatic levels from January 2012 to July 2018 were included.OUTCOME MEASURESThe primary outcome of interest was the development of symptomatic LDH at the previous asLDH of both groups that required reoperation. A second analysis was performed to compare the reoperation rate due to deterioration of asLDH among different severity grades of herniation. Reoperation rates of the original surgery at the symptomatic segment in both fusion and PELD groups were also reviewed.METHODSThe patients were divided into two groups based on the surgical procedure, with 264 patients undergoing fusion surgery and 107 patients undergoing PELD. Clinical and imaging follow-ups were performed at routine intervals for more than 3 years. The reoperation rates due to deterioration of previously asLDH and failure of original surgery were investigated and compared between the two groups, as well as among the different severity grades of herniation.RESULTSThe follow-up times were 48.2±24.2 and 41.1±17.5 months for the fusion and the PELD groups, respectively. The overall reoperation rate at the previous adjacent asLDH was 6.7% (25/317). According to the severity of the asLDH, a higher grade of asymptomatic herniation yielded a significantly higher rate of reoperation rate in both groups. If the nerve root was displaced by disc material prominently (nG2), the reoperation rate of asLDHs was 42.9% (3/7) in the fusion group and 20% (3/15) in the PELD group. Twenty out of 264 patients (7.6%) in the fusion group and 5 out of 107 patients (4.7%) in the PELD group required reoperation due to deterioration of asLDH. Reoperation rates due to failure of the original surgery were 7.6% (20/264) in the fusion group and 8.4% (9/107) in the PELD group.CONCLUSIONSWith multilevel LDHs, if the asLDH is left untreated, the reoperation rate is closely related to the degree of herniation. When confronting an asLDH graded as G2, a high possibility of reoperation should be clearly discussed with the patient, regardless of open fusion or PELD techniques. Considering that fusion and minimally invasive nonfusion techniques did not yield significantly different overall reoperation rates, ongoing degeneration seemed to have a greater contribution in terms of the deterioration of asLDH.     

Incidences,causes and risk factors of unplanned reoperations within 30 days of spine surgery: a single-center study based on 35,246 patients

BACKGROUND CONTEXTUnplanned reoperation, a quality indicator in spine surgery, has not been sufficiently investigated in a large-scale, single-center study.PURPOSETo assess the incidences, causes, and risk factors of unplanned reoperations within 30 days of spine surgeries in a single-center study.STUDY DESIGNRetrospective observational study.PATIENT SAMPLEA cohort of 35,246 patients who underwent spinal surgery in our hospital were included.OUTCOME MEASURESThe rates, chief reasons, and risk factors for unplanned reoperations within 30 days of spine surgery.METHODSWe retrospectively analyzed the data for patients who underwent spine surgeries for degenerative spinal disorders, tumor, or deformity and had subsequent unplanned operations within 30 days at a single tertiary academic hospital from January 2016 to July 2021. Univariate and multivariate analyses were performed to assess the incidences, causes, and risk factors.RESULTSOut of 35,246 spinal surgery patients, 297 (0.84%) required unplanned reoperations within 30 days of spine surgery. Patients with a thoracic degenerative disease (3.23%), spinal tumor (1.63%), and spinal deformity (1.50%) had significantly higher rates of reoperation than those with atlantoaxial (0.61%), cervical (0.65%), and lumbar (0.82%) degenerative disease. The common causes for reoperation included epidural hematoma (0.403%), wound infections (0.148%), neurological deficit (0.108%), and pedicle screw malposition (0.077%). Unplanned reoperations were classified as hyperacute (45.45%), acute (30.98%), subacute (15.82%), or chronic (7.74%). Univariate analysis indicated that 20 clinical factors were associated with unplanned reoperation (p<.05). Multivariate Poisson regression analysis revealed that anemia (p<.001), osteoporosis (p=.048), ankylosing spondylitis (p=.008), preoperative foot drop (p=.011), deep venous thrombosis (p<.001), and previous surgical history (p<.001) were independent risk factors for unplanned spinal reoperation.CONCLUSIONSThe incidence of unplanned spinal reoperations was 0.84%. The chief common causes were epidural hematoma, wound infections, neurological deficit, and pedicle screw malposition. Anemia, osteoporosis, ankylosing spondylitis, preoperative foot drop, deep venous thrombosis, and previous surgical history led to an increased risk of unplanned reoperation within 30 days of spine surgery.     

Fusion rate for stand-alone lateral lumbar interbody fusion: a systematic review

BACKGROUNDLateral lumbar interbody fusion (LLIF) is used to treat multiple conditions, including spondylolisthesis, degenerative disc disorders, adjacent segment disease, and degenerative scoliosis. Although many advocate for posterior fixation with LLIF, stand-alone LLIF is increasingly being performed. Yet the fusion rate for stand-alone LLIF is unknown.PURPOSEDetermine the fusion rate for stand-alone LLIF.STUDY DESIGNSystematic review.METHODSWe queried Cochrane, EMBASE, and MEDLINE for literature on stand-alone LLIF fusion rate with a publication cutoff of April 2020. LLIF surgery was considered stand-alone when not paired with supplemental posterior fixation. Cohort fusion rate differences were calculated and tested for significance (p<0.05). All reported means were pooled.RESULTSA total of 2,735 publications were assessed. Twenty-two studies met inclusion criteria, including 736 patients and 1,103 vertebral levels. Mean age was 61.7 years with BMI 26.5 kg/m². Mean fusion rate was 85.6% (range, 53.0%–100.0%), which did not differ significantly by number of levels fused (1-level, 2-level, and ≥3-level). Use of rhBMP-2 was reported in 39.3% of subjects, with no difference in fusion rates between studies using rhBMP-2 (87.7%) and those in which rhBMP-2 was not used (83.9%, odds ratio=1.37, p=0.448). Fusion rate did not differ with the addition of a lateral plate, or by underlying diagnosis. All-complication rate was 42.2% and mean reoperation rate was 11.1%, with 2.3% reoperation due to pseudarthrosis. Of the studies comparing stand-alone to circumferential fusion, pooled fusion rate was found to be 80.4% versus 91.0% (p=0.637).CONCLUSIONSStand-alone LLIF yields high fusion rates overall. The wide range of reported fusion rates and lower fusion rates in studies involving subsequent surgical reoperation highlights the importance of proper training in this technique and employing a rigorous algorithm when indicating patients for stand-alone LLIF. Future research should focus on examining risk factors and patient-reported outcomes in stand-alone LLIF.     

Reoperations after decompression with or without fusion for L4–5 spinal stenosis with or without degenerative spondylolisthesis: a study of 6,532 patients in Swespine,the national Swedish spine register

Background and purpose — There are different opinions on how to surgically address lumbar spinal stenosis with concomitant degenerative spondylolisthesis (DS). We investigated reoperation rates at the index and adjacent levels after L4–5 fusion surgery in a large cohort of unselected patients registered in Swespine, the national Swedish spine register.Patients and methods — 6,532 patients, who underwent surgery for L4–5 spinal stenosis with or without DS between 2007 and 2012, were followed up to 2017 to identify reoperations at the index and adjacent levels. The reoperation rates for decompression and fusion were compared with the reoperation rates for decompression only and for patients with or without DS. Patient-reported outcome data were collected preoperatively, and at 1 and 2 years after surgery and used to evaluate differences in outcome between index operations and reoperations.Results — For spinal stenosis with DS, the reoperation rate at the index level was 3.0% for decompression and fusion and 6.0% for decompression only. At the adjacent level, the corresponding numbers were 9.7% and 4.2% respectively. For spinal stenosis without DS, the reoperation rate at the index level was 3.7% for decompression and fusion and 6.2% after decompression only. At the adjacent level, the corresponding numbers were 8.1% and 3.8% respectively. For the reoperations at the adjacent level, there was no difference in patient-reported outcome between extended fusion or decompression only.Interpretation — Single-level lumbar fusion surgery is associated with an increased rate of reoperations at the adjacent level compared with decompression only. When reoperations at the index level are included there is no difference in reoperation rates between fusion and decompression only.

There is an ongoing controversy on how to surgically address lumbar spinal stenosis with and without concomitant degenerative spondylolisthesis (DS). The debate has focused on the durability of the index operation versus accelerated symptomatic degeneration at the adjacent segments. In this debate, durability has been defined as maintenance of clinical benefit without the need for additional intervention (Ghogawala et al. 2017). While decompression without fusion may increase the risk for early index-level reoperations for instability (Ghogawala et al. 2016, Urakawa et al. 2020), fusion surgery might increase the risk of adjacent segment disease (ASD) (Sears et al. 2011, Okuda et al. 2018).The national Swedish spine register (Swespine) covers 90% of the spine units in Sweden and the follow-up rate is 75–80% (Strömqvist et al. 2013). The Swespine offers possibilities to examine outcome in a large dataset of patients operated on for isolated L4–5 disease, which is the most common clinical scenario within spine surgery. Large register studies may contribute to increased evidence in this area.Using Swespine data, we investigated reoperation rates at the index and the adjacent levels after L4–5 decompression only or decompression and fusion for spinal stenosis with and without concomitant DS.     

Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study

Background context

Lumbar spinal stenosis is one of the most common degenerative spine diseases. Surgical options are largely divided into decompression only and decompression with arthrodesis. Recent randomized trials showed that surgery was more effective than nonoperative treatment for carefully selected patients with lumbar stenosis. However, some patients require reoperation because of complications, failure of bony fusion, persistent pain, or progressive degenerative changes, such as adjacent segment disease. In a previous population-based study, the 10-year reoperation rate was 17%, and fusion surgery was performed in 10% of patients. Recently, the lumbar fusion surgery rate has doubled, and a substantial portion of the reoperations are associated with a fusion procedure. With the change in surgical trends, the longitudinal surgical outcomes of these trends need to be reevaluated.

Purpose

To provide the longitudinal reoperation rate after surgery for spinal stenosis and to compare the reoperation rates between decompression and fusion surgeries.

Study design/setting

Retrospective cohort study using national health insurance data.

Patient sample

A cohort of patients who underwent initial surgery for lumbar stenosis without spondylolisthesis in 2003.

Outcome measures

The primary end point was any type of second lumbar surgery. Cox proportional hazards regression modeling was used to compare the adjusted reoperation rates between decompression and fusion surgeries.

Methods

A national health insurance database was used to identify a cohort of patients who underwent an initial surgery for lumbar stenosis without spondylolisthesis in 2003; a total of 11,027 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. After adjusting for confounding factors, the reoperation rates for decompression and fusion surgery were compared.

Results

Fusion surgery was performed in 20% of patients. The cumulative reoperation rate was 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 5 years. The adjusted reoperation rate was not different between decompression and fusion surgeries (p=.82). The calculated reoperation rate was expected to be 22.9% at 10 years.

Conclusions

The reoperation rate was not different between decompression and fusion surgeries. With current surgical trends, the reoperation rate appeared to be higher than in the past, and consideration of this problem is required.     

Adjacent segment pathology following posterior lumbar interbody fusion for lumbar degenerative spondylolisthesis: a comparison between minimally invasive and conventional open approach

BACKGROUND CONTEXTThe minimally invasive (MI) approach in posterior lumbar interbody fusion (PLIF) minimizes the muscle-stripping posterior exposure of the lumbar spine; therefore, it is hypothesized that such benefits would reduce adjacent segment pathology (ASP) development.OBJECTIVEThis study aimed to estimate the incidence of ASP following MI-PLIF.STUDY DESIGNRetrospective study.PATIENT SAMPLEA total of 100 patients who had undergone single-level PLIF at the L4/5 level for lumbar degenerative spondylolisthesis were retrospectively studied (MI-PLIF group: 68 patients; conventional open PLIF [O-PLIF] group; 32 patients; average follow-up period: 100.5 months).OUTCOME MEASURESIncidence of ASP.METHODSPatients were considered to have operative ASP (OASP) if adjacent segments manifested degenerative lesions that caused clinically significant symptoms requiring surgery. Survival curves were estimated for each group using the Kaplan–Meier method. The study was not externally funded. The authors have no conflicts of interest to declare.RESULTSFour (5.9%) of the 68 patients in the MI-PLIF group and 6 (18.8%) of the 32 patients in the O-PLIF group experienced OASP during the follow-up period. Kaplan–Meier analysis predicted a disease-free OASP survival rate of 98.5% (95% confidence interval [CI], 95.5%–100%) in the MI-PLIF group and 90.6% (95% CI, 81.1%–100%) in the O-PLIF group at 5 years, and 93.7% (95% CI, 86.8%–100%) in the MI-PLIF group and 71.8% (95% CI, 52.9%–97.5%) in the O-PLIF group at 10 years. MI-PLIF achieved a significantly higher survival rate in OASP than did O-PLIF (p=.04). O-PLIF was associated with a 3.97 times higher risk (odds ratio 3.97, 95% CI, 1.02–15.48; p=.04) of developing OASP in our cohort.CONCLUSIONSFollowing MI-PLIF, the rate of OASP was predicted to be 1.5% at 5 years and 6.3% at 10 years. MI-PLIF had a lower incidence of OASP and more favorable clinical outcomes than did O-PLIF.     

Revision lumbar fusions have higher rates of reoperation and result in worse clinical outcomes compared to primary lumbar fusions

BACKGROUND CONTEXTIndications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented.PURPOSEThe purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion.STUDY DESIGN/SETTINGRetrospective single-institution cohort study.PATIENT SAMPLEFour thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion.OUTCOME MEASURESHospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain.METHODSPatient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ?PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ?PROMs were then repeated based on the new groupings.RESULTSThere was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p<.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ?ODI, ?VAS Back, ?VAS Leg, and ?PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ?PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ?VAS Leg (ref: ASD, β=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ?PROMs when compared to isolated decompressions.CONCLUSIONSRevision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ?PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.     

Adjacent segment stenosis after lumbar fusion requiring second operation

Background Whereas degeneration of the segment adjacent to lumbar fusion has been often seen on radiographs, a small number of patients with such degenerative changes undergo reoperation. Most follow-up studies have focused on adjacent segment disease based on analysis of radiographs. The present study was conducted to understand the pathology of reoperation cases of adjacent segment disease and factors associated with this condition. Operative indication was consistently restricted to patients with neurological involvement. Methods The subjects were 117 patients who had undergone posterior lumbar fusion and were followed for a minimum of 2 years (mean 7 years). Among them, nine patients (7.7%) required a second operation owing to symptomatic adjacent segment disease (stenosis). The reoperation rate was assessed in relation to sex, age, initial pathologic condition, and initial spinal fusion and decompression methods. Data were analyzed in a 2 × 2 cross contingency table using Fisher's exact probability test. A probability of <0.05 was defined as statistically significant. Results Of the variables examined, only multilevel fusion was associated with a high rate of reoperation with statistical significance (P < 0.04). Two patients (100%) suffering from loss of coronal balance (degenerative scoliosis) also required a second operation. Conclusions The reoperation rate of 7.7% for adjacent segment disease in this study was consistent with the prevalence of adjacent segment stenosis in the literature. Given the risk of later occurrence of adjacent segment stenosis following multisegment posterolateral fusion, correction of coronal and sagittal balance, preventive decompression of the adjacent segment, or selective decompression without fusion may have to be considered as an additional or alternative procedure.     

Should patients with lumbar stenosis and grade I spondylolisthesis be treated differently based on spinopelvic alignment? A retrospective,two-year,propensity matched,comparison of patient-reported outcome measures and clinical outcomes from multiple sites within a single health system

BACKGROUNDDegenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored.PURPOSEThis study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion.STUDY DESIGN/SETTINGRetrospective sub-group analysis of observational, prospectively collected cohort study.PATIENT SAMPLE679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center.OUTCOME MEASURESThe primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition.METHODSRadiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as “high” and “low” mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of “cases” (fusion) and “controls” (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch.RESULTS49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152).CONCLUSIONSLumbar laminectomy with fusion was superior to laminectomy in health–related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.     

Longitudinal Spinous‐Splitting Laminoplasty with Coral Bone for the Treatment of Cervical Adjacent Segment Degenerative Disease: A 5‐Year Follow‐up Study

This study was designed to analyze the causes of cervical adjacent segment degenerative disease (ASDis), evaluate the surgical outcomes of longitudinal spinous‐splitting laminoplasty with coral bone (SLAC) during cervical reoperation, and accumulate data on reoperation with SLAC in a primary hospital. Based on the inclusion and exclusion criteria, we conducted a retrospective study involving 52 patients who underwent cervical reoperation for ASDis using SLAC at the spinal surgery department of the Beijing Jishuitan Hospital from 1998 to 2014. Among them, 39 were treated with anterior cervical fusion and internal fixation during the first operation (anterior cervical corpectomy with fusion [ACCF], n = 24; anterior cervical discectomy and fusion [ACDF], n = 11; and cervical disc arthroplasty [CDA], n = 4). Outcomes were the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI) score, upper limb/neck and shoulder evaluated using a visual analogue scale (VAS), and rates of ASDis. In patients who underwent an anterior cervical approach in the first instance, the incidence of ASDis was significantly higher in the C_3/4 gap than in the other gaps. In the ACCF group, the lateral radiograph of the cervical spine revealed that the distance between the anterior cervical plate and the adjacent segment disc was <5 mm in 15 (62.5%) cases and five (12.8%) cases, respectively, the internal fixation screws broke into the annulus of the adjacent segment. After the first SLAC, ASDis developed at C_2/3 and C_3/4 in four (30.8%) and eight (61.5%) cases, respectively. After reoperation, all cases were followed up for >5 (average, 6.2) years. The pre‐reoperation and last follow‐up values were as follows: mean Japanese Orthopaedic Association score, 10.2 ± 1.5 vs 15.5 ± 0.7 (P = 0.03); neck disability index, 26.2 vs 13.6 points (P = 0.01); upper‐limb visual analog scale (VAS) score, 6.1 vs 2.6 points (P = 0.04); and neck and shoulder VAS score, 6.6 vs 2.1 points (P = 0.03). SLAC is a simple technique in which the local anatomy is clearly visible and satisfactory clinical outcomes are obtained.     

Thirty-day unplanned reoperations of thoracic spine surgery: 10 years of data from a single center with 3242 patients

BACKGROUND CONTEXTUnplanned reoperation is a useful quality indicator for spine surgery. However, the rates of a 30-day unplanned reoperation in patients undergoing thoracic spinal surgery are not well established.PURPOSETo assess the rates, reasons, and risk factors of 30-day unplanned reoperations for thoracic spine surgeries in a single center study.STUDY DESIGNA retrospective observational study.PATIENT SAMPLEA total of 3242 patients who underwent thoracic spinal surgery at our institution in the past decade were included.OUTCOME MEASURESThe incidence, chief reasons, and risk factors for unplanned reoperations within 30 days after thoracic spinal surgery.METHODSWe retrospectively analyzed the data of all patients who underwent thoracic spinal surgery between January 2012 and December 2021. Statistical methods, including univariate and multivariate analyses, were performed to assess the incidence, reasons, and risk factors for thoracic degenerative diseases, spinal tumors, kyphosis deformity, and spinal trauma.RESULTSOf the 3242 patients who underwent thoracic spinal surgery, 107 (3.30%) required unplanned reoperations within 30 days due to epidural hematoma (1.17%), wound complications (0.80%), implant complications (0.43%), inadequate decompression (0.25%), and other causes (0.65%). Patients with degenerative disease (3.88%), spinal tumor (2.98%), and kyphosis deformity (3.33%) had significantly higher incidences of reoperation than those with spinal trauma (1.47%). Unplanned reoperations were classified as hyperacute (30.84%), acute (31.76%), and subacute (37.38%). After univariate analysis, several factors were associated with unplanned reoperation in the 4 cohorts of thoracic spine diseases (p<.05). Multivariate logistic regression analysis revealed that upper thoracic spine surgery (p=.001), concomitant dekyphosis (p=.027), and longer activated partial thromboplastin time (p=.025) were risk factors of unplanned reoperation for thoracic degenerative disease. Whereas American Society of Anesthesiologists (ASA) grade III (p=.015), combined approach (p=.016), and operation time longer than 420 min (p=.042) for spinal tumor, and similar ankylosing spondylitis (p=.023) and operation time longer than 340 min (p=.041) were risk factors of unplanned reoperation for kyphosis deformity.CONCLUSIONSThe unplanned reoperation rate for thoracic spine surgery was 3.30%, with epidural hematoma and wound complications being the most common reasons. However, upper thoracic spine surgery, concomitant dekyphosis, underlying coagulation disorder, longer operation time, higher ASA grade, and comorbidities of ankylosing spondylitis led to an increased risk of unplanned reoperation within 30 days of thoracic spine surgery.     

Pedicle screws versus cortical screws in posterior lumbar interbody fusion surgery for degenerative spondylolisthesis: a systematic review and meta-analysis

BACKGROUND CONTEXTA few meta-analyses have compared conventional pedicle screws (PS) with cortical bone trajectory-pedicle screws (cortical screw [CS]) in posterior lumbar fusion surgery. However, these studies did not control for diagnosis, which has been shown to impact surgical outcomes.PURPOSETo compare PS with CS as a posterior fixation technique in posterior lumbar interbody fusion (PLIF) for degenerative spondylolisthesis (DS).STUDY DESIGNSystematic review and meta-analysis.METHODSWe searched the Cochrane, Embase, and Medline databases for articles that compared postoperative outcomes between PS and CS for posterior stabilization in PLIF for DS with November 11, 2020, as the publication cutoff. The differences in primary and secondary outcome measures were calculated and analyzed for significance (p<.05). All the reported means were pooled.RESULTSA total of 916 publications were assessed; 5 studies met all the study criteria. The fusion rates between PS and CS groups were not significantly different (p=.41). Blood loss and operative time were significantly less in the CS group than the PS group (p=.04 and 0.02, respectively), but the length of stay was not significantly different (p=.08). The total complication rate was significantly less in CS group than that in PS group (p=.002). The rates of adjacent segment pathology (ASP) and operation for ASP in the CS group were significantly less than the PS group (p=.03 and .04, respectively).CONCLUSIONSThough CS and PS appear to have similar 1-year fusion rates and length of stay, there appears to lower blood loss and operative time with CS. Though encouraging, these findings were based on low-quality evidence from a small number of retrospective studies that are prone to bias.     

Pre-existing adjacent level foraminal stenosis does not affect the outcome of a single level lumbar interbody fusion

BackgroundThe aim of this study was to investigate whether or not pre-existing asymptomatic neuroforaminal stenosis adjacent to the fusion level develops adjacent segment disease (ASD) after single-level lumbar interbody fusion.Summary and background dataRisk factors of ASD after spinal fusion have been well investigated, but there have been few studies focused on the relationship between ASD and pre-existing asymptomatic neuroforaminal stenosis.MethodsA total of 302 patients who had undergone a single-level lumbar interbody fusion were reviewed at a minimum of 2 year follow-up. They were 109 men and 193 women with a mean age of 68.8 years. Follow-up periods was averaged 53.5 months. ASD was defined as neurological deterioration related to adjacent segment pathologies which required an additional surgery. Based on the pathologies, patients were divided into three categories: ASD due to foraminal stenosis (ASD-FS), ASD due to central stenosis (ASD-CS), and ASD due to herniated disc (ASD-HD). Measured variables were age, gender, diagnosis, BMI, decompression procedures at adjacent segments, preoperative anterior/posterior slip, asymptomatic neuroforaminal stenosis, facet tropism, and postoperative spinopelvic parameters.ResultsThirty-eight patients (12.6%) developed ASD. There were 15 patients with ASD-FS, 18 patients with ASD-CS, and five patients with ASD-HD. Lumbar lordosis (LL) and sacral slope (SS) were significantly smaller and pelvic tilt (PT) was significantly larger in ASD-FS. Asymptomatic neuroforaminal stenosis was detected preoperatively in 33.3% of the ASD-FS group, and 18.6% of non-ASD group; the incidence was not significantly different.ConclusionsAdjacent-level neuroforaminal stenosis was not a significant risk of ASD after single-level lumbar interbody fusion, and might not need to be fused if asymptomatic.     

Efficacy of translaminar facet screw fixation in circumferential interbody fusions as compared to pedicle screw fixation

OBJECTIVES: Posterior lumbar fixation with translaminar facet screws is a minimally invasive technique with good success rates. Long-term follow-ups show reduced reoperation rates, a decrease in pain scores, and few complications compared with pedicle screw fixation devices. The purpose of this study was to compare the reoperation rate of translaminar facet screw fixation with that of pedicle screw fixation in 360 degrees anterior and posterior fusions for incapacitating low back pain due to lumbar disc degeneration unresponsive to at least 6 months of aggressive nonoperative treatment. METHODS: One hundred five patients underwent a combined circumferential lumbar fusion with posterior fixation for discogenic pain by one surgeon between August 1993 and February 2003. Seventeen patients were excluded from the study owing to their preoperative etiology for fusion or a prior instrumented posterior fusion. A retrospective chart review was done on all 88 remaining patients. Patients were followed in the office, by phone, or by mail to obtain functional outcome measures. Any subsequent operations by this surgeon or another were recorded. The comparison focused on the rate of reoperation on the region of posterior lumbar fixation. RESULTS: Sixty-seven patients have had at least a 2-year follow-up. Twenty-four patients had a posterior fusion with pedicle screws, and 43 had translaminar facet screw fixation. Nine patients of the pedicle screw population (37.5%) had a reoperation to remove their instrumentation. Two patients of the translaminar facet screw population (4.7%) had reoperations on their lumbar spine. There was a significant association between posterior instrumentation type and reoperation (P = 0.001). CONCLUSION: The success of translaminar facet screws in circumferential fusions is justified.