Analog Scale Back Pain Research Articles

269. Clinically relevant improvement is maintained 5 years after surgery for spinal stenosis

BACKGROUND CONTEXT Lumbar spinal stenosis (LSS) is a common condition in the elderly population and is associated with significant morbidity and decreased quality of life. Many patients manage with little to no treatment, but for the patients in whom lower extremity pain and disability are unacceptable, surgical intervention is shown to provide good relief of symptoms and pain. There is little evidence on how many patients obtain a clinically relevant improvement in function and whether this effect is sustained 5 years after surgery. PURPOSE The aim of this study was to evaluate the proportion of patients who achieve and maintain a clinically relevant improvement at 1, 2 and 5 years postoperatively. STUDY DESIGN/SETTING The study was performed as a retrospective cohort study on patients who underwent surgery at the Spine Centre of Southern Denmark, Middelfart; The Regional Hospital of Silkeborg and University Hospital of Zealand in Koge. PATIENT SAMPLE A total of 6,063 patients who underwent decompression due to spinal stenosis at three spine centers in Denmark were included in our study. We had follow-up data available on our main outcome measure (ODI) on 75% at 1-year, 70% at 2-year, and 62% at 5-year follow-up. OUTCOME MEASURES Oswestry Disability Index (ODI), EuroQoL-5D-3L (EQ-5D), visual analogue scale leg pain (VAS-leg) and visual analogue scale back pain (VAS-back). METHODS We included patients who underwent first-time decompression due to LSS at three tertiary Spine Centers in Denmark. Data was collected prospectively in the National Spine Registry of Denmark (DaneSpine). Based on the outcome measures, the patients who obtained a minimal clinically relevant difference in outcome (MCID) were identified at 1-, 2- and 5-years post-surgery. RESULTS The mean change from baseline to 5-years post-surgery was 0.2 on EQ-5D; -18.9 on ODI, -18.9 on VAS back and 29.8 on VAS. We found that 86% of patients obtained the MCID on at least one parameter, with 68.9% obtaining MCID on two or more outcome measures. VAS back was found with a statistically important difference in the percentage of patients who achieved MCID at 1- and 5-years postsurgery. For the remaining outcome measures no statistically important difference was found. CONCLUSIONS Decompression as treatment for LSS is a safe and reliable option with low complication rates. Most patients achieve a clinically relevant difference in outcome on one or more parameters, which is maintained 5 years after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Preoperative Chronic Opiate Use and Patient Reported Outcomes Following Adult Spinal Reconstructive Surgery

Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery. Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively. Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group. Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery.

Are Modic Changes Associated With Health-related Quality of Life After Discectomy: A Study on 620 Patients With Two-year Follow-up.

A registry-based comparative cohort study with 2-year follow-up. To assess whether Modic changes (MCs) are associated with health-related quality of life, long-term physical disability, back- or leg pain after discectomy. Previous studies have failed to show a clinically significant association between MCs and patient-reported outcomes (PROs) after discectomy. Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014 to 2017 with an accessible preoperative lumbar magnetic resonance imaging, complete preoperative, and 2-year follow-up questionnaires were obtained. PROs including Oswestry disability index (ODI), European Quality of Life-Five Dimensions (EQ-5D), visual analogue scale (VAS) back and leg pain, and patient satisfaction were collected. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI. Of 620 patients included, MCs were present in 290 patients (47%). Of these, MC type 1 (MC-1) was present in 73 (25%) and MC type 2 (MC-2) in 217 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PROs from baseline compared with 2-year follow-up (P < 0.001). At 2-year follow-up, both groups had improved with no significant difference between them in regards to ODI (15.5 vs. 17.2, P = 0.208); EQ-5D (0.75 vs. 0.72, P = 0.167); VAS-BP (27.1 vs. 28.3, P = 0.617); VAS-LP (26.8 vs. 25.0, P = 0.446); and patient satisfaction (74% vs. 76%, P = 0.878). MCs were not found to be associated with health-related quality of life, disability, back- or leg pain, or patient satisfaction 2 years after discectomy. 2.

Cross-cultural adaptation and validation of the Arabic version of the Core Outcome Measures Index for the back (COMI-back) in patients with non-specific low back pain.

To cross-culturally adapt the Core Outcome Measures Index for the back (COMI-back) for the Arabic language and to test its reliability and validity in Egyptian patients with non-specific low back pain (LBP). COMI-back was translated and cross-culturally adapted into Arabic according to standard guidelines. Its construct validity was assessed in 85 patients with chronic LBP (mean (± SD) age, 41.1 (± 10.4) years and 65/85 (76.5%) female) who completed a booklet of questionnaires including the Arabic versions of COMI-back, Roland Morris disability questionnaire, Oswestry disability index, the short form health survey 36, and the visual analogue scale for back pain. Test-retest reliability was assessed in 52 participants who completed the booklet again within 7days. Floor effects (worst status; 1.2-10.6%) and ceiling effects (best status; 1.2-11.8%) for COMI-back were acceptable, except for symptom-specific well-being (18.8%, floor), leg pain (23.5%, ceiling), and work disability (31.8%, ceiling). The COMI item scores correlated with those of the reference questionnaires (ρ = 0.45-0.88) to the hypothesized extent, except for the COMI symptom-specific well-being (ρ = 0.16-0.17) and quality of life (ρ = 0.38). The intra-class correlation coefficient for the summary score was 0.90, whereas that of the individual items ranged from 0.71-0.92. The standard error of measurement and minimal detectable change for the summary score were 0.51 and 1.41 points, respectively. The predefined hypotheses for construct validity and reliability were largely confirmed. The Arabic version of COMI-back represents a valid and reliable instrument for use in Arabic-speaking patients with non-specific LBP.

Preoperative patient activation is predictive of improvements in patient-reported outcomes following minimally invasive lumbar decompression.

To determine whether there is an association between preoperative 10-Item Patient Activation Measure (PAM-10) scores and clinical outcomes following MIS LD. Patients undergoing a primary MIS LD were retrospectively reviewed and stratified according to their preoperative PAM-10 scores: "low PAM," "moderate PAM," and "high PAM." Preoperative PAM score cohorts were tested for improvements in Oswestry Disability Index (ODI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) back and leg pain using multivariate linear regression. Eighty-nine patients were included: 29 had a low PAM score, 32 had a moderate PAM score, and 28 had a high PAM score. Cohorts experienced similar preoperative VAS back pain, VAS leg pain, ODI, and SF-12 PCS. Patients with low PAM scores experienced a trend of higher pain scores throughout 6 months with VAS back pain being significant at 3 months and VAS leg pain being significant at 6-week and 3-month follow-up. Patients with lower PAM scores experienced a worse improvement in ODI at 6-week, 3-month, and 6-month timepoints. Lastly, patients with lower PAM scores demonstrated less improvement in SF-12 PCS at 3-month and 6-month follow-up. Lower preoperative PAM scores were associated with worse improvement in clinical outcomes following MIS LD. Patients with lower PAM scores had diminished improvement in long-term patient-reported outcomes including ODI, SF-12, and VAS back and leg pain. Our investigation suggests that preoperative PAM assessments may be an effective tool to predict postoperative outcomes following MIS LD.

Evaluation of Efficacy of Neuro Muscular Electrical Stimulation and Electro Acupuncture in Improving the Pain and Disability in Patients with the Lumbar Degenerative Intervertebral Disk Disease

Background: Chronic low back pain (CLBP) due to the degenerative intervertebral disk diseases is one of the most common musculoskeletal conditions in contemporary societies. A variety of pharmacological, non-pharmacological and surgical options is available for treatment of CLBP. The use of non-pharmacological methods have drastically increased in recent years, offering fewer complications and expenses. This study was conducted to compare the efficacy of the neuromuscular electrical stimulation (NMES) and electro acupuncture (EAP) with exercise therapy alone in patients with chronic low back pain. Materials and Methods: This was a randomized case-controlled clinical trial. Sixty patients with CLBP were randomly assigned to 3 groups (20 cases each) of the EAP with exercise therapy, NMES with exercise therapy, and exercise therapy only. Severity of pain and disability improvement were assessed using the visual analog scale (VAS) and Quebec back pain disability scale respectively. Results: A total of 66 individuals were enrolled, out of which 6 were excluded due to patients’ lack of cooperation. A significant decline in the amounts of Quebec and VAS was observed in the three groups (p<0.001). The pain and disability improvements did not display any significant difference in the NMES or EAP groups compared to the control group. However, the severity of disability and pain in the NMES group were significantly higher than the EAP group (p<0.05). Conclusion: These findings may indicate an almost identical efficacy of exercise therapy alone compared to the combination with electrical stimulation techniques in improving the pain and disability in patients suffering CLBP.

Interbody fusion in degenerative lumbar spinal stenosis with additional posterolateral fusion using Escherichia coli-derived bone morphogenetic protein-2: A Pilot study.

This case series investigated the efficacy and optimal dose of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2) as a bone graft substitute for additional posterolateral spinal fusion, accompanying interbody fusion procedures, for treating lumbar degenerative spinal stenosis. This study focused on the optimal dose for each segment and the efficacy of E.BMP-2 as a substitute for autogenous iliac bone graft.Ten patients were enrolled from January 2015 to December 2015, and underwent an additional posterolateral fusion procedure, with 2.5 mg of E.BMP-2 followed by decompression, transpedicular fixation, and interbody fusion. The mean follow-up period was 13.9 months, and regular radiological examinations were performed in every case. Clinical outcomes were measured with a visual analog scale for back pain (VAS-BP), and leg pain (VAS-LP) and the Korean Oswestry Disability Index (K-ODI). All parameters were assessed preoperatively and postoperatively at 12 months.All 18 segments treated with E.BMP-2 completely fused in 6 months as observed on both simple radiography and computed tomography. The mean fusion period was 4.5 months on simple radiography. At 12 months follow-up, VAS-BP, VAS-LP, and K-ODI scores (1.9 ± 1.5, 1.9 ± 1.9, 11.0 ± 6.6, respectively) had improved significantly compared to preoperative scores (5.5 ± 1.9, 6.5 ± 1.9, and 49.9 ± 11.5, respectively, P < .05). There were no postoperative wound infections, neurological symptoms, or complications associated with the use of E.BMP-2 during the follow-up period.E.BMP-2 could be used to enhance the outcomes in posterolateral spinal fusion following interbody fusion surgery. In the present study, 2.5 mg of the E.BMP-2 per segment was sufficient to obtain bony union in posterolateral fusion surgery. Further large-scale trials with long-term follow-up are necessary to evaluate the various complications related to the use of E.BMP-2.

Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia could be a satisfying treatment alternative for young patient with symptomatic lumbar spondylolysis: a technique note with case series

BackgroundMultiple surgical procedures are applied in young patients with symptomatic lumbar spondylolysis when conservative treatments fail. Although the optimal surgical procedure option is controversial, the treatment paradigm has shifted from open surgery to minimally invasive spine surgery. To date, a limited number of studies on the feasibility of percutaneous endoscopic-assisted direct repair of pars defect have been carried out. Herein, for the first time, we retrospectively explore the outcomes of pars defect via percutaneous endoscopy.MethodsWe retrospectively examined young patients with spondylolysis treated using the percutaneous endoscopic-assisted direct repair of pars defect supplemented with autograft as well as percutaneous pedicle screw fixation between September 2014 and December 2018. Six patients with a mean age of 18.8 years were enrolled in the study. We used preoperatively computed tomographic (CT) scans to evaluate the size of pars defect, and graded disc degeneration using Pfirrmann’s classification through magnetic resonance images (MRI). We assessed the clinical outcomes using the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36) as well as Visual Analogue Scale for back pain (VAS-B).ResultsOur findings revealed that pain intensity and function outcomes, including VAS-B, ODI, and SF-36 (PCS and MCS) scores, were markedly improved after surgery and at the final follow-up visit. The change in the gap distance of the pars defect was remarkably significant after surgery and during the follow-up period. Only one of the 12 pars repaired was reported as a non-union at the final follow-up visit. Moreover, no surgery-related complications were reported in any of the cases.ConclusionPercutaneous endoscopic-assisted direct repair of pars defect without general anesthesia, a minimally invasive treatment option, supplemented with autograft and percutaneous pedicle screw fixation, could be a satisfying treatment alternative for young patients with symptomatic lumbar spondylolysis.

Does Smoking Affect Short-Term Patient-Reported Outcomes After Lumbar Decompression?

Study Design:Retrospective cohort study.Objective:The goal of this study was to determine how smoking status influences patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery.Methods:Patients undergoing lumbar decompression between 1 to 3 levels at a single-center, academic hospital were retrospectively identified. Patients <18 years old, and those undergoing surgery for infection, trauma, tumor, or revision, with less than 12 months of follow-up were excluded. Patients were divided into 3 groups: (1) never smokers (NSs); (2) current smokers (CSs); and (3) former smokers (FSs). PROMs analyzed included the Physical Component Score and Mental Component Score of the Short Form-12 Health Survey, the Oswestry Disability Index, and Visual Analogue Scale Back and Leg pain scores. One-way ANOVA was used to compare preoperative and postoperative scores between smoking groups, and multiple linear regression analysis was performed to determine whether smoking status predicted change in each outcome score, controlling for factors such as age, sex, body mass index, and other clinical variables. A P value <.05 was considered to be significant.Results:A total of 195 patients were included in the final cohort, with 121 (62.1%) patients in the NS group, 22 (11.3%) in the CS group, and 52 (26.6%) in the FS group. There were no significant differences between groups at baseline or postoperatively. Smoking status was also not a significant predictor of change in any outcome scores over time on multivariate analysis.Conclusion:These results suggest that smoking status does not significantly affect short-term complications or outcomes in patients undergoing lumbar decompression surgery.

How Does Smoking Influence Patient-reported Outcomes in Patients After Lumbar Fusion?

A retrospective cohort study. The goal of this study was to determine the effect of smoking on patient-reported outcome measurements (PROMs) after lumbar fusion surgery. Although smoking is known to decrease fusion rates after lumbar fusion, there is less evidence regarding the influence of smoking on PROMs after surgery. Patients undergoing between 1 and 3 levels of lumbar fusion were divided into 3 groups on the basis of preoperative smoking status: never smokers (NS); current smokers (CS); and former smokers (FS). PROMs collected for analysis include the Physical Component Score (PCS-12), Mental Component Score (MCS-12), Oswestry Disability Index (ODI), and Visual Analogue Scale back (VAS back) and leg (VAS leg) pain scores. Preoperative and postoperative PROMs were compared between groups. A multiple linear regression analysis was performed to determine whether preoperative smoking status was a predictor of change in PROM scores. A total of 220 (60.1%) NS, 52 (14.2%) CS, and 94 (25.7%) FS patients were included. Patients in most groups improved within each of the PROMs analyzed (P<0.05). VAS leg pain (P=0.001) was found to significantly differ between groups, with NS and FS having less disability than CS (3.6 vs. 2.0, P=0.010; and 3.6 vs. 2.4, P=0.022; respectively). Being a CS significantly predicted less improvement in ODI (P=0.035), VAS back (P=0.034), and VAS leg (P<0.001) compared with NS. In addition, NS had a significantly lower 30-day readmission rate than CS or FS (3.2% vs. 5.8% and 10.6%, respectively, P=0.029). CS exhibited worse postoperative VAS leg pain and a lower recovery ratio than never smokers. In addition, being in the CS group was a significant predictor of decreased improvement in ODI, VAS back, and VAS leg scores. Level III.

Fusion and Healing Prediction in Posterolateral Spinal Fusion Using 18F-Sodium Fluoride-PET/CT

This study measures the total graft of 18F-sodium fluoride (NaF) uptake in non-instrumented posterolateral lumbar fusion (niPLF) patients one month after surgery and correlates it with the difference in the clinical findings between the baseline and one year after surgery. The walking distance (WLK-D), visual analog scale of back pain (VAS-B), VAS score of leg pain (VAS-L), tandem test (TAN), Oswestry Disability Index questionnaire (ODI), and European Quality of Life-5 Dimensions questionnaire (EQ-5D) were assessed before surgery and one year after. The graft NaF uptake was analyzed quantitatively with a fixed threshold algorithm resulting in the total graft uptake (SUVtotal) and partial volume corrected SUVtotal (cSUVtotal). Only 4 out of 18 patients experienced fusion; they had an insignificantly lower median total graft uptakes, i.e., 1178 SUVtotal vs. 1224 SUVtotal (p = 0.73) and 1282 cSUVtotal vs. 1231 cSUVtotal (p = 0.35), respectively. Similarly, fused patients experienced insignificantly larger pain decreases, i.e., median VAS-B 4.3 vs. 3.8 (p = 0.92) and VAS-L −6.4 vs. −4.4 (p = 0.2). We found an insignificant trend for a lower NaF uptake and less pain in fused patients. The NaF uptake did not correlate with the chronological change in the clinical parameters.

How Does Body Mass Index Influence Outcomes in Patients After Lumbar Fusion?

Retrospective study. The purpose of the present study is to determine how body mass index (BMI) affects patient-reported outcome measurements (PROMs) after lumbar fusions. Although greater preoperative BMI is known to increase the rates of adverse events after surgery, there is a paucity of literature assessing the influence of BMI on PROMs after lumbar fusion. Patients undergoing lumbar fusion surgery between 1 and 3 levels were retrospectively identified. PROMs analyzed were the Short Form-12 Physical Component Score, Mental Component Score, Oswestry Disability Index (ODI), and Visual Analog Scale Back and Leg pain scores. Patients were divided into groups based on preoperative BMI: class 1, BMI <25.0; class 2, BMI 25.0 to 29.9; class 3, BMI 30.0 to 34.9; and class 4, BMI ≥35.0. Absolute PROM scores, the recovery ratio, and the percentage of patients achieving minimum clinically important difference between groups were compared. A total of 54 (14.8%) patients in class 1, 140 (38.2%) in class 2, 109 (29.8%) in class 3, and 63 (17.2%) in class 4 were included. All patients improved after surgery across all outcome measures (P < 0.001) except for class 4 patients, who did not improve in terms of Short Form-12 Mental Component Score scores after surgery (P = 0.276). Preoperative Short Form-12 Physical Component Score (P = 0.002) and Oswestry Disability Index (P < 0.0001) scores were significantly different between BMI groups-with class 4 having worse disability than class 1 and 2. BMI was not a significant predictor for any outcome domain. Overall 30- and 90-day readmission rates were similar between groups, with a higher revision rate in the class 4 group (P = 0.036), due to a higher incidence of postoperative surgical site infections (P = 0.014). All patients undergoing short-segment lumbar fusion for degenerative disease improved to a similar degree with respect to PROMs. Those in the highest class of obesity (BMI ≥35.0) were, however, at a greater risk for postoperative surgical site infection. 3.

Correlation of Early Outcomes and Intradiscal Interleukin-6 Expression in Lumbar Fusion Patients.

ObjectiveTo determine if there is correlation between intradiscal levels of interleukin-6 (IL-6) and early outcome measures in patients undergoing lumbar fusion for painful disc degeneration. MethodsIntervertebral disc tissue was separated into annulus fibrosus/nucleus pulposus and cultured separately in vitro in serum-free medium (Opti-MEM). Conditioned media was collected after 48 hours. The concentration of IL-6 was quantified using enzyme-linked immunosorbent assay. Pearson correlation coefficients quantified relationships between IL-6 levels and pre- and postoperative visual analogue scale (VAS) back pain and Oswestry Disability Index (ODI), as well as change in VAS/ODI. ResultsSixteen discs were harvested from 9 patients undergoing anterior lumbar interbody fusion (mean age, 47.4 years; range, 21–70 years). Mean preoperative and 6-month postoperative VAS were 8.1 and 3.7, respectively. Mean preoperative and postoperative ODI were 56.2 and 25.6, respectively. There were significant positive correlations between IL-6 expression and postoperative VAS (ρ = 0.38, p = 0.048) and ODI (ρ = 0.44, p = 0.02). No significant correlations were found between intradiscal IL-6 expression and preoperative VAS (ρ = -0.12, p = 0.54). Trends were seen associating IL-6 expression and change in VAS/ODI (ρ = -0.35 p = 0.067; ρ = -0.34, p = 0.08, respectively). A trend associated IL-6 and preoperative ODI (ρ = 0.36, p = 0.063). ConclusionThe direct association between IL-6 expression and VAS/ODI suggests patients with elevated intradiscal cytokine expression may have worse early outcomes than those with lower expression of IL-6 after surgery for symptomatic disc degeneration.

Predicting treatment adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain.

There is a growing need to identify patient pre-treatment characteristics that could predict adherence and outcome following specific interventions. To identify predictors of adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain (CLBP). A total of 273 CLBP patients participated in an exercise-based rehabilitation program. Patients who completed ⩾ 70% of the treatment course were classified as adherent. Patients showing a post-treatment reduction of ⩾ 30% in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) back pain intensity scores were assigned to the favorable outcome group. Multivariate logistic regression revealed that higher age, higher ability to perform low-load activities, and higher degrees of kinesiophobia increased the odds to complete the rehabilitation program. By contrast, lower levels of education and back pain unrelated to poor posture increased the odds for non-adherence. Furthermore, a favorable outcome was predicted in case the cause for LBP was known, shorter symptom duration, no pain in the lower legs, no difficulties falling asleep, and short-term work absenteeism. Assessment and consideration of patient pre-treatment characteristics is of great importance as they may enable therapists to identify patients with a good prognosis or at risk for non-responding to outpatient multimodal rehabilitation.

Preoperative Mental Health Component Scoring Is Related to Patient Reported Outcomes Following Lumbar Fusion.

Retrospective cohort review. The objective of this study was to identify depression using the Mental Component Score (MCS-12) of the Short Form-12 (SF-12) survey and to correlate with patient outcomes. The impact of preexisting depressive symptoms on health-care related quality of life (HRQOL) outcomes following lumbar spine fusion is not well understood. Patients undergoing lumbar fusion between one to three levels at a single center, academic hospital were retrospectively identified. Patients under the age of 18 years and those undergoing surgery for infection, trauma, tumor, or revision, and less than 1-year follow-up were excluded. Patients with depressive symptoms were identified using an existing clinical diagnosis or a score of MCS-12 less than or equal to 45.6 on the preoperative SF-12 survey. Absolute HRQOL scores, the recovery ratio (RR) and the percent of patients achieving minimum clinically important difference (MCID) between groups were compared, and a multiple linear regression analysis was performed. A total of 391 patients were included in the total cohort, with 123 (31.5%) patients reporting symptoms of depression based on MCS-12 and 268 (68.5%) without these symptoms. The low MCS-12 group was found to have significantly worse preoperative Oswestry disability index (ODI), visual analogue scale back pain (VAS Back) and visual analogue scale leg pain (VAS Leg) scores, and postoperative SF-12 physical component score (PCS-12), ODI, VAS Back, and VAS Leg pain scores (P < 0.05) than the non-depressed group. Finally, multiple linear regression analysis revealed preoperative depression to be a significant predictor of worse outcomes after lumbar fusion. Patients with depressive symptoms, identified with an MCS-12 cutoff below 45.6, were found to have significantly greater disability in a variety of HRQOL domains at baseline and postoperative measurement, and demonstrated less improvement in all outcome domains included in the analysis compared with patients without depression. However, while the improvement was less, even the low MCS-12 cohort demonstrated statistically significant improvement in all HRQOL outcome measures after surgery. 3.

Minimally Invasive Spine Lumbar Surgery in Obese Patients: A Systematic Review and Meta-Analysis.

Transforaminal lumbar interbody fusion (TLIF) is the treatment of choice for lumbar spinal stenosis and spondylolisthesis. The procedure can be performed through a traditional open approach (O-TLIF) or through minimally invasive techniques (MI-TLIF). Spinal surgeries in obese patients can pose risks, including increased rates of infection and thromboembolic events. We sought to systematically review the literature on the differences between MI-TLIF and O-TLIF in the obese patient in terms of complication rate, functional outcomes, blood loss, and length of hospital stay. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically search PubMed, Embase, Web of Science, and the Cochrane Library for studies published through February 2019 and identified those comparing the outcomes of O-TLIF and MI-TLIF in obese patients. The primary outcome was complication rate (total, infections, dural tears); secondary outcomes were blood loss, length of hospital stay, and functional scores. Two authors independently reviewed the studies using the Newcastle-Ottawa Scale, and data were pooled using the Mantel-Haenszel random-effects model. In the sample of 430 patients, the average age was 53.5years, there were 153 men and 203 women, and the average body mass index was 33.6. Complications were significantly higher in O-TLIF than in MI-TLIF (OR = 0.420 [95% CI: 0.199, 0.887]; I 2 = 45.20%). No difference was detected between the two groups for visual analog scale back pain scores and Oswestry Disability Index scores between the pre-operative and last follow-up visits (SMD = -0.034 [95% CI -0.695, 0.627]; I 2 = 62.14% and SMD = 0.617 [95% CI: -1.082, 2.316]; I 2 = 25%, respectively). Blood loss was significantly lower in MI-TLIF compared to O-TLIF (SMD = -426.736 [95% CI: -490.720, -362.752]; I 2 = 70.53%), as was the duration of hospital stay (SMD = -1.079 [95% CI: -1.591, -0.208]; I 2 = 84.3%). MI-TLIF has equivalent efficacy to O-TLIF in obese patients at long-term follow-up. In addition, complication rate, blood loss, and length of hospital stay were lower in MI-TLIF than in O-TLIF.

Awake, Endoscopic Revision Surgery for Lumbar Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: Technical Notes

We sought to evaluate the feasibility for awake, endoscopic treatment of lumbar pseudarthrosis after a transforaminal lumbar interbody fusion (TLIF). A 71-year-old male with severe cardiac disease, determined to be high risk for general anesthesia, presented with mechanical back pain and a L3-4 pseudarthrosis and L3 pedicle screw loosening after a L3-5 TLIF. An awake, transforaminal endoscopic redo diskectomy and TLIF procedure were performed by removing residual disk material adjacent to the previous "PEEK" (polyetheretherketone) interbody spacer and placing allograft, bone morphogenetic protein, and an expandable titanium interbody device adjacent to the PEEK cage. At 1-year follow-up, preoperative visual analog scale for back pain and Oswestry disability index improved from 7 and 38% to 1 and 2%. The 1-year follow-up radiograph showed stable interbody placement and no further screw loosening. A minimally invasive, awake procedure is presented for the treatment of pseudarthrosis after TLIF.

Postoperative Outcomes Based on American Society of Anesthesiologists Score After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

A retrospective cohort study. To examine the association between the American Society of Anesthesiologists (ASA) score and patient-reported outcomes (PROs) after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Few studies have investigated the correlation between ASA score and PROs after MIS TLIF. Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed and placed into 3 cohorts: ASA score ≤2 and outpatient status, ASA score ≤2 and inpatient status, and ASA score >2. Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, and Short Form-12 Physical Component Score (SF-12 PCS) were administered preoperatively and at 6-week, 12-week, and 6-month time points. ASA scores were tested for association with improvements in PROs using linear regression. A total of 187 patients had an ASA score ≤2 and 41 patients had an ASA score >2. Higher ASA scores were associated with older age, obesity, higher comorbidity burden, and an increased length of stay. ASA subgroups demonstrated a significant difference in preoperative ODI and VAS back pain scores and improvement in VAS back pain scores at the 12-week and 6-month time points; however, there was no discernible pattern of improvement amongst cohorts. No statistically significant differences were observed with improvements in PROs. The study suggests ASA scores are not associated with postoperative recovery in pain and disability after MIS TLIF. Our results indicate that regardless of the preoperative ASA score, patients are likely to achieve similar improvements in PROs through 6 months follow-up. Although using ASA as a risk stratification tool to predict perioperative complications, its utility in predicting improvement in PROs is still uncertain at this time.

Design of a randomized trial of teriparatide followed by alendronate: Japanese Osteoporosis Intervention Trial-05 (JOINT-05).

Despite advances in drug treatment, the optimal treatment strategy for severe osteoporosis remains uncertain. This article reports the design and rationale for the Japanese Osteoporosis Intervention Trial-05 (JOINT-05), a randomized, controlled trial that compares the efficacy and safety of teriparatide followed by alendronate with alendronate monotherapy for severe osteoporosis. Postmenopausal women aged at least 75years were eligible for the study if they were at high risk of fracture. Patients were recruited from 113institutions in Japan between October 2014 and December 2017. They were randomly assigned in a 1:1 ratio to the sequential therapy arm (once-weekly subcutaneous injections of teriparatide 56.5μg for 72weeks followed by alendronate for 48weeks) or monotherapy arm (alendronate for 120weeks). The regimens for alendronate are 5mg (orally administered once daily), 35mg (orally administered once weekly), or 900μg (intravenously administered once every 4weeks). The primary endpoint is the incidence of morphometric vertebral fracture at 72weeks. The secondary endpoints include the incidence of morphometric vertebral fracture at 120weeks; incidence of morphometric vertebral or non-vertebral fractures at 72 and 120weeks; incidence of clinical vertebral fracture at 72 and 120weeks; changes in bone mineral density, quality of life scores (EuroQol 5 Dimensions and the Japanese Osteoporosis Quality of Life Questionnaire short form), and a visual analog scale for back pain; and adverse events. We reported the design and rationale for the JOINT-05. The trial is registered with the Japan Registry of Clinical Trials (jRCTs031180235) and the University Hospital Medical Information Network-Clinical Trials Registry (UMIN000015573).

Efficacy of platelet-rich plasma in posterior lumbar interbody fusion: systematic review and meta-analysis.

We have conducted a systematic review and meta-analysis that aims to compare outcomes (pain VAS, fusion and adverse event) of PRP and placebo after posterolateral lumbar fusion (PLF) surgery. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies were identified from Medline and Scopus from inception to September 16, 2019 that reported visual analog scale back pain, postoperative complications and fusions of either group. In a total of seven studies, two, two, three studies were RCT, prospective and retrospective studies, respectively. Overall, there were 270 patients (150 in the PRP group and 149 in the placebo group). Three, three, four, three, two, seven and four studies were reported for pain VAS back in 3months, 6months, 12months, 24months, period of fusion, postoperative fusion and adverse events, respectively. The unstandardized mean difference (UMD) VAS back in 3, 6, 6 and 24months was -0.41 (95%CI -0.87, 0.05) score, -0.97 (95%CI -1.68, -0.27) score, -0.33 (95%CI -0.61, -0.59) score, -0.19 (95%CI -1.00, 0.62) scores lower than placebo after posterolateral lumbar fusion (PLF) patients. The UMD period of bone union were -1.62 (95%CI -1.85, -1.39) months faster than placebo after PLF patients. A total of seven and four studies were reported fusion and adverse events between PRP and placebo group. No significant differences were noted for fusion and adverse events with the pooled RR of 1.03 (95%CI 0.48, 1.80) and 0.95 (95%CI 0.14, 6.56). PRP with autologous bone graft had lower back pain and faster bone union time than bone graft alone. While, there have no difference in fusion rate and adverse events in both groups. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient. Further research including cost of operation, postoperative function and satisfaction, quality of life and cost-efficacy analysis is required to determine whether the PRP with autologous bone graft is superior to bone graft alone or not. Level II.