Improvement In Leg Pain Research Articles

Advantages of a Microsurgical Translaminar Approach (Keyhole Laminotomy) for Upper Lumbar Disc Herniation

To prevent risk of iatrogenic instability after surgery for upper lumbar disc herniation, we adapted a microsurgical translaminar approach (keyhole laminotomy), which allows less destructive laminotomy. We compared results of translaminar and interlaminar approaches. The study enrolled 48 patients who underwent single-level discectomy in the upper lumbar spine (L1-2 or L2-3). Patients were allocated to 2 groups: a translaminar group (n= 20) or an interlaminar group (n= 28). Mean patient age was 57.04 ± 12.77 years, and median follow-up duration was 3.5 years (range, 1.0-7.0 years). Clinical and radiologic data were retrospectively reviewed. Baseline characteristics, including age, sex, surgical level, and preoperative symptoms, were nonsignificantly different. At 1 year after surgery, improvement in leg pain as determined by visual analog scale was nonsignificantly different. Improvement in visual analog scale for back pain was significantly greater in the translaminar group compared with interlaminar group (mean 4.00 ± 1.56 vs. 2.45 ± 2.01, P < 0.001). Surgical outcome was not different between groups. Mean decrease in disc height at operated level was not significantly different between groups. Mean increase in segmental range of motion at surgical levels was significantly greater in the interlaminar group (-3.38 ± 4.03° vs. 1.10 ± 3.03°, P= 0.010), and mean recovery of total lumbar lordosis was significantly greater in the translaminar group (9.80 ± 5.96° vs. 0.43 ± 8.45°, P= 0.021). The translaminar approach provides a safe and effective alternative to the classic interlaminar approach for upper lumbar disc herniation.

WITHDRAWN: Midline Lumbar Fusion Using Cortical Bone Trajectory Screws for Elderly Patients

Summary Background Midline lumbar fusion (MIDLF) using cortical bone trajectory (CBT) is an alternative method of lumbar spinal fusion. It is useful for reduction not only for approach-related morbidity but also for osteoporosis. This study aimed to present our experience with MIDLF, and focused on survey of postoperative wound pain intensity and outcome assessment. Methods We retrospectively collected patients who met criteria of elderly (age more than 65 years old), spondylolisthesis, disc herniation, or spinal stenosis, and those who received MIDLF operation. By reviewing medical records, we analysed pain scores, complication rates, and screws loosening. Results Between January 2016 and June 2017, 23 patients were enrolled. One patient had screw malposition who needed reoperation. The rest patients showed significant improvement of the leading symptom. The visual analogue scale (VAS) scores for wound pain on the first postoperative day, second postoperative day, and before discharge were 3.4, 2.3, and 1.4, respectively. Early ambulation was achieved owing to the mild postoperative pain. The mean VAS scores for lower back and leg pain improvement were 4.7 and 4.5 respectively in the 3-month follow-up. At the most recent follow-up, all the patients reported maintenance of the satisfactory result. No screw-loosening or other complications were noted. Conclusions In our experience, MIDLF using CBT route seemed to reduce post-op wound pain significantly, so that elderly patients could ambulate earlier. It also had less screws loosening, especially for elderly or osteoporotic patients.

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery

Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery. To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement. This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017. Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more. A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator). The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.

Minimally invasive surgery versus open surgery in the treatment of lumbar spondylolisthesis: study protocol of a multicentre, randomised controlled trial (MISOS trial)

IntroductionPatients with symptomatic spondylolisthesis are frequently treated with nerve root decompression, in addition to pedicle screw fixation and interbody fusion. Minimally invasive approaches are gaining attention in recent years, although...

1-Year Results of a Randomized Controlled Trial of Conservative Management vs. Minimally Invasive Surgical Treatment for Sacroiliac Joint Pain

Background: Low back pain (LBP) emanating from the sacroiliac joint (SIJ) is a common finding. Devices to fuse the SIJ are now commercially available, but high-quality evidence supporting their effectiveness is limited. Objectives: To compare the safety and effectiveness of conservative management (CM) to minimally invasive sacroiliac joint fusion (SIJF) in patients with chronic LBP originating from the SIJ. Study Design: Prospective, multicenter randomized controlled trial. Setting: One hundred three adults in spine clinics with chronic LBP originating from the SIJ. Methods: Patients were randomly assigned to CM (n = 51) or SIJF using triangular titanium implants (n = 52). CM consisted of optimization of medical therapy, individualized physiotherapy, and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated LBP at 6 months using a 0 – 100 visual analog scale (VAS). Other effectiveness and safety endpoints, including leg pain, disability using Oswestry Disability Index (ODI), quality of life using EQ-5D, and SIJ function using active straight leg raise test (ASLR), were assessed up to 12 months. Results: At 12 months, mean LBP improved by 41.6 VAS points in the SIJF group vs. 14.0 points in the CM group (treatment difference of 27.6 points, P &lt; 0.0001). Mean ODI improved by 25.0 points in the SIJF group vs. 8.7 points in the CM group (P &lt; 0.0001). Mean improvements in leg pain and EQ-5D scores were large after SIJF and superior to those after CM. CM patients were allowed to crossover to SIJF after 6 months. Patients who crossed to surgical treatment had no pre-crossover improvement in pain and ODI scores; after crossover, improvements were as large as those originally assigned to SIJF. One case of postoperative nerve impingement occurred in the surgical group. Two SIJF patients had recurrent pain attributed to possible device loosening and one had postoperative hematoma. In the CM group, one crossover surgery patient had recurrent pain requiring a revision surgery. Limitations: The primary limitation was lack of blinding and the subjective nature of self-assessed outcomes. Conclusions: For patients with chronic LBP originating from the SIJ, minimally invasive SIJF with triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, and improving patient function and quality of life. Our findings will help to inform decisions regarding its use as a treatment option in this patient population.

101 Lumbar Fusion Versus Laminectomy for Spondylolisthesis

Abstract INTRODUCTION The AANS/CNS Spine Section Study Group analyzed 12-month outcomes data from for patients undergoing either laminectomy with fusion or laminectomy alone for grade 1 degenerative spondylolisthesis at ten sites. METHODS 475 patients undergoing elective spine surgery for degenerative grade 1 lumbar spondylolisthesis were identified by retrospective analysis of prospectively collected data from the QOD spine registry. Patients with more than one level fusion were excluded (n = 121) leaving a 354 patient cohort. Patients undergoing 1 level fusion with 1–3 levels of laminectomy (n = 274) were compared to those undergoing 1–3 levels of laminectomy alone (n = 80). RESULTS &gt;For patients presenting with Grade1 spondylolisthesis, 23% (80/354) underwent laminectomy alone while 77% (274/354) underwent 1 level fusion with laminectomy. The percentage of cases returning to the OR within one year was similar for the laminectomy (6.2%) versus the fusion group (6.9%). At baseline, the fusion group had higher NRS back pain (7.0 ± 2.4 vs 5.94 ± 3.0, P&lt; 0.01) and ODI (46.2 ± 15.3 vs 36.8 ± 16.3, P&lt; 0.001) scores than the laminectomy alone group, however, NRS leg pain scores were equivalent. When comparing absolute difference in outcomes at 12-months to baseline, NRS back pain (4.1 ± 2.9 vs 3.1 ± 3.5, P = 0.05) and ODI (25.7 ± 16 vs 19.0 ± 17, P&lt; 0.01) scores improved to a greater extent in the fusion group compared to laminectomy alone group whereas NRS leg pain scores improved equally. Patient satisfaction scores were equivalent for both surgical groups. CONCLUSION The data indicate that fusion with laminectomy for grade 1 degenerative lumbar spondylolisthesis is associated with low readmission and re-operation rates. Patients in the laminectomy with fusion group report more baseline back pain (NRS-back pain) and disability (ODI). Patients undergoing fusion with laminectomy report greater improvement in back pain and less disability at 12-months as compared to those in the lam group, while both groups had equivalent improvement in leg pain.

Outcome of Anterior Lumbar Interbody Fusion: A Retrospective Study of Clinical and Radiologic Parameters.

This study critically evaluates the long-term results of standalone anterior lumbar interbody fusion (ALIF), without use of rhBMP-2, as a therapeutic option for symptomatic patients with degenerative disc disease (DDD). Furthermore, this study intends to identify predictive parameters for anterior lumbar interbody fusion outcome. A retrospective cohort study with additional telephone interview to obtain missing data was performed. All patients who underwent an L4-L5 or L5-S1 ALIF-procedure, or both, in the period between 2006 and 2011 were identified. The medical files of 123 patients with 154 fusion levels were reviewed. All patients were contacted by telephone to gather supplementary and missing information. Pain and functionality scores (Visual Analogue Scale [VAS] and Oswestry Disability Index [ODI]), radiologic (intervertebral disc height, Modic and Pfirrmann classifications), and different clinical parameters were gathered. The mean age of the population at surgery was 46.2 years. Overall, 59 female and 64 male patients were included in the study. The mean VAS score for back and leg pain improved significantly (P < 0.001) with 5 and 4.4 points respectively at 3-year follow-up. Modic-type I changes are associated with a better improvement in VAS score for back pain (P= 0.026), Pfirrmann-grades IV and V and an intervertebral disc height of less than 5 mm are associated with a better improvement in leg pain (respective P-values: 0.045 and 0.033). Overall, 89% of patients would reconsider the surgical intervention. The ALIF technique is a durable treatment option for patients with DDD. This study suggests different predictive parameters for treatment outcome.

The prognostic value of preoperative participation in activities of daily living on postoperative outcomes following lumbar discectomy

ObjectivesIn other surgical fields, preoperative level of participation in activities of daily living (ADLs) has been found to be important in predicting outcomes. To date, postoperative ADL measurements have only been used to characterize outcomes following lumbar discectomy. The present study's goal was to determine if patients’ preoperative ability to perform ADLs correlates with their postoperative outcomes after lumbar discectomy at 3 months and 1 year. Patients and methodsThis retrospective study was performed using prospectively collected data from patients prospectively enrolled in a randomized clinical trial. All patients were 18 years or older, spoke English, had not previously had lumbar surgery, and underwent discectomy for a single-level lumbar disc herniation. Oswestry disability index (ODI) and visual analogue scale (VAS) back and leg pain scores were collected preoperatively and at 3 months and 1 year postoperatively. Simple linear regression analysis was performed to detect any significant correlations between three preoperative ODI domain values and postoperative scores. Additionally, regression analysis was used to determine the correlation between the preoperative ODI domains and percentage of good and poor outcomes, where an improvement of at least 18.8 points for ODI and at least 2 points for VAS constituted a good outcome. Results90 subjects satisfied inclusion criteria (average age 42, 53 males, 37 females). Patients’ ability to take care of themselves and to stand preoperatively were correlated with improvement in ODI postoperatively, with worse ability corresponding to more improvement (p<0.001 for both). Only personal care scores correlated with good improvement in leg pain. No significant correlations were found with back pain. When evaluating patients by dichotomized outcome (good or poor), only preoperative ability to participate in personal care was consistently significantly correlated to a good outcome. ConclusionThis is the first study to suggest that lower preoperative ability to take part in personal care might predict better surgical outcomes after discectomy. The current data might prompt reassessment of the importance of ADLs in pre-operative patient evaluation and may help anticipate outcomes following lumbar discectomy.

Sacroiliac Joint Fusion: One Year Clinical and Radiographic Results Following Minimally Invasive Sacroiliac Joint Fusion Surgery.

Background:Recalcitrant sacroiliac joint pain responds well to minimally-invasive surgical (MIS) techniques, although long-term radiographic and fusion data are limited.Objective:To evaluate the one-year clinical results from a cohort of patients with chronic sacroiliac (SI) joint pain unresponsive to conservative therapies who have undergone minimally invasive SI joint fusion.Methods:SI joint fusion was performed between May 2011 and January 2014. Outcomes included radiographic assessment of fusion status, leg and back pain severity via visual analog scale (VAS), disability via Oswestry Disability Index (ODI) and complication rate. Outcomes were measured at baseline and at follow-up appointments 6 months and 12 months post-procedure.Results:Twenty minimally invasive SI joint fusion procedures were performed on 18 patients (mean age: 47.2 (14.2), mean BMI: 29.4 (5.3), 56% female). At 12 months, the overall fusion rate was 88%. Back and leg pain improved from 81.7 to 44.1 points (p<0.001) and from 63.6 to 27.7 points (p=0.001), respectively. Disability scores improved from 61.0 to 40.5 (p=0.009). Despite a cohort containing patients with multiple comorbidities and work-related injuries, eight patients (50%) achieved the minimal clinically important difference (MCID) in back pain at 12 months, with 9 (69%) patients realizing this improvement in leg pain and 8 (57%) realizing the MCID in ODI scores at 12 months. No major complications were reported.Conclusion:Minimally invasive SI joint surgery is a safe and effective procedure, with a high fusion rate, a satisfactory safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure.

The effect of preoperative dexamethasone on pain 1year after lumbar disc surgery: a follow-up study.

BackgroundIt has been hypothesized that dexamethasone can inhibit persistent postoperative pain, but data on humans is lacking and results from animal studies are conflicting. We explored the effect of 16 mg dexamethasone IV administered preoperatively on persistent pain 1 year after lumbar discectomy.MethodsThis is a prospective 1-year follow-up on a single-centre, randomized, and blinded trial exploring the analgesic effect of 16 mg IV dexamethasone or placebo after lumbar discectomy. One year follow-up was a written questionnaire including back and leg pain (VAS 0–100 mm), Short Form 36 survey (SF-36), EuroQol 5D (EQ-5D), OSWESTRY Low Back Pain Questionnaire, duration of sick leave, working capability, contentment with surgical result.ResultsResponse rate was 71% (55 patients) in the dexamethasone group, 58% (44 patients) in the placebo group. Leg pain (VAS) was significantly lower in the placebo group compared to the dexamethasone group: 17 (95% CI 10–26) vs 26 (95% CI 19–33) mm, respectively (mean difference 9 mm (95% CI −1 to 0), (P = 0.03). No difference regarding back pain. The placebo group reported significantly more improvement of leg pain and were significantly more satisfied with the surgical result. Patients in the dexamethasone group reported significantly higher pain levels in EQ-5D- and Oswestry questionnaires. No difference in the SF-36 survey or daily analgesic consumption.ConclusionsWe found significantly higher pain levels in the dexamethasone group compared to placebo 1 year after lumbar disc surgery.Trial registrationClinicaltrials.gov (NCT01953978). Registered 26 Sep 2013.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study

Introduction: Since the introduction of lumbar microdiscectomy in the 1970’s, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice. Methods and analysis: This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

Open discectomy vs microdiscectomy for lumbar disc herniation - a protocol for a pragmatic comparative effectiveness study.

Introduction: Since the introduction of lumbar microdiscectomy in the 1970's, many studies have attempted to compare the effectiveness of this method with that of standard open discectomy with conflicting results. This observational study is designed to compare the relative effectiveness of microdiscectomy (MD) with open discectomy (OD) for treating lumbar disc herniation, -within a large cohort, recruited from daily clinical practice. Methods and analysis: This study will include patients registered in the Norwegian Registry for Spine Surgery (NORspine). This clinical registry collects prospective data, including preoperative and postoperative outcome measures as well as individual and demographic parameters. The primary outcome is change in Oswestry disability index between baseline and 12 months after surgery. Secondary outcome measures are improvement of leg pain and changes in health related quality of life measured by the Euro-Qol-5D between baseline and 12 months after surgery, complications to surgery, duration of surgical procedures and length of hospital stay.

Percutaneous Endoscopic Lumbar Discectomy as an Alternative to Open Lumbar Microdiscectomy for Large Lumbar Disc Herniation

Remarkable advancements in endoscopic spinal surgery have led to successful outcomes comparable to those of conventional open surgery. Large lumbar disc herniation (LLDH) is a serious condition, resulting in higher surgical failure when accessing the herniated disc. This study compared the outcomes of LLDH treated with percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM). Retrospective assessment. This retrospective observational study was conducted from January 2011 to June 2012. Forty-four consecutive patients diagnosed with LLDH without cauda equina syndrome who were scheduled to undergo spinal surgery were included. LLDH was defined as herniated disc fragment occupying > 50% of the spinal canal. Clinical outcomes were evaluated using a visual analogue scale (VAS, 0 - 10), functional status was assessed using the Oswestry Disability Index (ODI, 0 - 100%) at 1, 6, and 24 months postoperatively and surgical satisfaction rate (0 - 100%) at final follow up. Radiological variables were assessed by plain radiography. Forty-three patients were included; 20 and 23 patients underwent PELD and OLM, respectively. Both groups exhibited significant improvements in leg and back pain postoperatively (P < 0.001). Although there was no significant difference in leg pain improvement between the groups, improvement in back pain was significantly higher in the PELD group than in the OLM group (4.9 ± 1.5 vs. 2.5 ± 1.0, P < 0.001). The surgical satisfaction rate of the PELD group was significantly higher than that of the OLM group (91.3% ± 6.5 vs. 84.3% ± 5.2, P < 0.001). Mean operating time, hospital stay, and time until return to work were significantly shorter in the PELD group than in the OLM group (67.8 vs. 136.7 minutes, 1.5 vs. 7.2 days, and 4.2 vs. 8.6 weeks; P < 0.001). Disc height (%) decreased significantly from 23.7 ± 3.3 to 19.1 ± 3.7 after OLM (P < 0.001), but did not change significantly after PELD (23.6 ± 3.2 to 23.4 ± 4.2; P = 0.703). The segmental angle of the operated level increased from 10.3° to 15.4° in the PELD group, which was significantly higher than that in the OLM group (9.6° to 11.6°; P = 0.038). In the OLM group, there was one case of fusion due to instability. In the PELD group, one case required revision surgery and another case experienced recurrence. There were no perioperative complications in either group. The study was retrospective with a small sample size and short follow-up period. PELD can be an effective treatment for LLDH, and it is associated with potential advantages, including a rapid recovery, improvements in back pain, and disc height preservation.

Transforaminal Percutaneous Endoscopic Discectomy for Lumbar Disc Herniation in Parkinson's Disease: A Case-Control Study.

Study DesignA case-control study.PurposeTo investigate the effectiveness of transforaminal percutaneous endoscopic discectomy (TPED) in Parkinson's disease (PD).Overview of LiteraturePatients with PD frequently suffer from radiculopathy and low back pain. Additionally, they demonstrate higher complication rates after open spine surgery. However, the clinical outcome of minimally invasive techniques for lumbar discectomy, such as TPED, have not been established for this population.MethodsPatients diagnosed with lumbar disc hernia were divided into Group A (11 patients diagnosed with PD), and Group B (10 patients as the control, non-PD group). All patients underwent TPED. Indexes of visual analogue scale (VAS) for leg pain and Oswestry disability index (ODI) were assessed right before surgery and at six weeks, three months, six months and one year post-surgery.ResultsAt the baseline visit, groups did not differ significantly with age (p=0.724), gender (p=0.835), level of operation (p=0.407), ODI (p=0.497) and VAS (p=0.772). Parkinson's patients had higher scores in ODI at every visit, but the outcome was statistically significant only at 3 months (p=0.004) and one year (p=0.007). Similarly, VAS measurements were higher at each time point, with the difference being significant at 3 (p<0.001), 6 (0.021), and 12 (p<0.001) months after surgery. At the end of a year of follow up, ODI was reduced by 49.6% (±16.7) in Group A and 59.2% (±8.0) in Group B (p=0.111), translating to a 79.5% (±13.0) and 91.5% (±4.1) average improvement in daily functionality (p=0.024). VAS was reduced by 59.1 mm (±11.8) in Group A and 62.2 mm (±7.4) in Group B (p=0.485), leading to an 85.3 % (±4.0) and 91.9% (±2.6) general improvement in leg pain (p<0.001).ConclusionsOur data indicate that TPED led to satisfactory improvement in leg pain and daily living in PD patients a year after surgery.

Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction.

OBJECT Back and leg pain are the primary outcomes of adult spinal deformity (ASD) and predict patients' seeking of surgical management. The authors sought to characterize changes in back and leg pain after operative or nonoperative management of ASD. Outcomes were assessed according to pain severity, type of surgical procedure, Scoliosis Research Society (SRS)-Schwab spine deformity class, and patient satisfaction. METHODS This study retrospectively reviewed data in a prospective multicenter database of ASD patients. Inclusion criteria were the following: age > 18 years and presence of spinal deformity as defined by a scoliosis Cobb angle ≥ 20°, sagittal vertical axis length ≥ 5 cm, pelvic tilt angle ≥ 25°, or thoracic kyphosis angle ≥ 60°. Patients were grouped into nonoperated and operated subcohorts and by the type of surgical procedure, spine SRS-Schwab deformity class, preoperative pain severity, and patient satisfaction. Numerical rating scale (NRS) scores of back and leg pain, Oswestry Disability Index (ODI) scores, physical component summary (PCS) scores of the 36-Item Short Form Health Survey, minimum clinically important differences (MCIDs), and substantial clinical benefits (SCBs) were assessed. RESULTS Patients in whom ASD had been operatively managed were 6 times more likely to have an improvement in back pain and 3 times more likely to have an improvement in leg pain than patients in whom ASD had been nonoperatively managed. Patients whose ASD had been managed nonoperatively were more likely to have their back or leg pain remain the same or worsen. The incidence of postoperative leg pain was 37.0% at 6 weeks postoperatively and 33.3% at the 2-year follow-up (FU). At the 2-year FU, among patients with any preoperative back or leg pain, 24.3% and 37.8% were free of back and leg pain, respectively, and among patients with severe (NRS scores of 7-10) preoperative back or leg pain, 21.0% and 32.8% were free of back and leg pain, respectively. Decompression resulted in more patients having an improvement in leg pain and their pain scores reaching MCID. Although osteotomies improved back pain, they were associated with a higher incidence of leg pain. Patients whose spine had an SRS-Schwab coronal curve Type N deformity (sagittal malalignment only) were least likely to report improvements in back pain. Patients with a Type L deformity were most likely to report improved back or leg pain and to have reductions in pain severity scores reaching MCID and SCB. Patients with a Type D deformity were least likely to report improved leg pain and were more likely to experience a worsening of leg pain. Preoperative pain severity affected pain improvement over 2 years because patients who had higher preoperative pain severity experienced larger improvements, and their changes in pain severity were more likely to reach MCID/SCB than for those reporting lower preoperative pain. Reductions in back pain contributed to improvements in ODI and PCS scores and to patient satisfaction more than reductions in leg pain did. CONCLUSIONS The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.

Does Transforaminal Lumbar Interbody Fusion Have Advantages over Posterolateral Lumbar Fusion for Degenerative Spondylolisthesis?

Study Design Retrospective cohort study. Objective To compare the clinical and radiographic outcomes of transforaminal lumbar interbody fusion (TLIF) and posterolateral lumbar fusion (PLF) in the treatment of degenerative spondylolisthesis. Methods This study compared 24 patients undergoing TLIF and 32 patients undergoing PLF with instrumentation. The clinical outcomes were assessed by visual analog scale (VAS) for low back pain and leg pain, physical component summary (PCS) of the 12-item Short-Form Health Survey, and the Oswestry Disability Index (ODI). Radiographic parameters included slippage of the vertebra, local disk lordosis, the anterior and posterior disk height, lumbar lordosis, and pelvic parameters. Results The improvement of VAS of leg pain was significantly greater in TLIF than in PLF unilaterally (3.4 versus 1.0; p = 0.02). The improvement of VAS of low back pain was significantly greater in TLIF than in PLF (3.8 versus 2.2; p = 0.02). However, there was no significant difference in improvement of ODI or PCS between TLIF and PLF. Reduction of slippage and the postoperative disk height was significantly greater in TLIF than in PLF. There was no significant difference in local disk lordosis, lumbar lordosis, or pelvic parameters. The fusion rate was 96% in TLIF and 84% in PLF (p = 0.3). There was no significant difference in fusion rate, estimated blood loss, adjacent segmental degeneration, or complication rate. Conclusions TLIF was superior to PLF in reduction of slippage and restoring disk height and might provide better improvement of leg pain. However, the health-related outcomes were not significantly different between the two procedures.

Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques.

It is hypothesized that minimally invasive surgical techniques lead to fewer complications than open surgery for adult spinal deformity (ASD). The goal of this study was to analyze matched patient cohorts in an attempt to isolate the impact of approach on adverse events. Two multicenter databases queried for patients with ASD treated via surgery and at least 1 year of follow-up revealed 280 patients who had undergone minimally invasive surgery (MIS) or a hybrid procedure (HYB; n = 85) or open surgery (OPEN; n = 195). These patients were divided into 3 separate groups based on the approach performed and were propensity matched for age, preoperative sagittal vertebral axis (SVA), number of levels fused posteriorly, and lumbar coronal Cobb angle (CCA) in an attempt to neutralize these patient variables and to make conclusions based on approach only. Inclusion criteria for both databases were similar, and inclusion criteria specific to this study consisted of an age > 45 years, CCA > 20°, 3 or more levels of fusion, and minimum of 1 year of follow-up. Patients in the OPEN group with a thoracic CCA > 75° were excluded to further ensure a more homogeneous patient population. In all, 60 matched patients were available for analysis (MIS = 20, HYB = 20, OPEN = 20). Blood loss was less in the MIS group than in the HYB and OPEN groups, but a significant difference was only found between the MIS and the OPEN group (669 vs 2322 ml, p = 0.001). The MIS and HYB groups had more fused interbody levels (4.5 and 4.1, respectively) than the OPEN group (1.6, p < 0.001). The OPEN group had less operative time than either the MIS or HYB group, but it was only statistically different from the HYB group (367 vs 665 minutes, p < 0.001). There was no significant difference in the duration of hospital stay among the groups. In patients with complete data, the overall complication rate was 45.5% (25 of 55). There was no significant difference in the total complication rate among the MIS, HYB, and OPEN groups (30%, 47%, and 63%, respectively; p = 0.147). No intraoperative complications were reported for the MIS group, 5.3% for the HYB group, and 25% for the OPEN group (p < 0.03). At least one postoperative complication occurred in 30%, 47%, and 50% (p = 0.40) of the MIS, HYB, and OPEN groups, respectively. One major complication occurred in 30%, 47%, and 63% (p = 0.147) of the MIS, HYB, and OPEN groups, respectively. All patients had significant improvement in both the Oswestry Disability Index (ODI) and visual analog scale scores after surgery (p < 0.001), although the MIS group did not have significant improvement in leg pain. The occurrence of complications had no impact on the ODI. Results in this study suggest that the surgical approach may impact complications. The MIS group had significantly fewer intraoperative complications than did either the HYB or OPEN groups. If the goals of ASD surgery can be achieved, consideration should be given to less invasive techniques.

Limited Microdiscectomy for Lumbar Disk Herniation

Surgical treatment of lumbar disk herniation is traditionally accomplished by removal of the extruded fragment as well as an aggressive decompression of the disk space. This retrospective study evaluates the long-term results of limited discectomy, otherwise known as fragmentectomy, for lumbar disk herniation using a minimally invasive technique. Although there are ample studies in literature regarding short-term outcome after limited microdiscectomy, there is a paucity of literature for long-term outcomes after fragmentectomy. We present long-term outcomes averaging 7 years after limited discectomy. A total of 152 patients were operated on between January 1, 2001 and June 30, 2003 for single-level herniated lumbar disks. All patients had microsurgical fragmentectomy performed through a small skin incision off the midline using a tubeless retraction system. Fifty-four patients participated in the study, whereas 98 patients were lost to long-term follow-up. Long-term outcome was assessed by telephone survey or mail-in survey using the Oswestry Low Back Pain Disability Index and a patient outcome survey. After Institutional Review Board approval and patient consent, all 54 patients had a thorough chart review for evaluation of further lumbar surgeries. The mean long-term follow-up was 86.2 months (range, 72-104 mo) or about 7.2 years. Forty-eight of the 54 patients (88.9%) reported an excellent (26 patients) or good (22 patients) long-term outcome with surgery. Long-term back and leg pain improvement was seen in 44 of 49 (89.8%) and 44 of 50 (88.0%) patients reporting back or leg pain, respectively. The mean Oswestry Disability Index for long-term follow-up was 8.89, indicating minimal disability. Same-level recurrences requiring reoperation were seen in 6 of the 54 patients who participated (11.1%) within the average 86.2-month follow-up. Four of 34 (11.85%) known contained herniations and 2 of 20 (10.0%) known extruded herniations presented for same-level surgical recurrence. All recurrences were successfully treated with reexploration and fragmentectomy. Two patients from the recurrence group and 1 from the original 54 progressed to need an arthrodesis at the initial operated level (5.6%). One patient in the same-level recurrence group and 2 patients from the original 54 developed an operative herniated disk at an adjacent level (5.6%). Our long-term outcome study shows that a minimally invasive approach to microdiscectomy with removal of the fragment only is an effective way to treat lumbar disk herniation. The rate of recurrence in our long-term study seems slightly higher compared with previously published studies, which generally had shorter follow-up periods. Long-term patient outcomes for back and leg pain were also very low. No appreciable difference in operative reherniation could be found with patients who had contained verses extruded fragments. It is difficult to predict from this study whether a simple fragmentectomy was the cause of the progression to further surgeries or whether this was the natural progression of a degenerative spine. Further prospective trials are necessary to fully understand the factors associated with limited microdiscectomy.

Percutaneous interspinous distraction device for the treatment of lumbar spinal canal stenosis: clinical and radiographic results at 2-year follow-up.

ObjectiveTo evaluate the effectiveness of the In- space (Synthes, Umkirch, Germany) and the correlation between radiographic parameters and clinical outcome in patients with lumbar spinal canal stenosis (LSS).MethodsBetween June 2009 and May 2013, 56 patients with LSS underwent In-space by one senior surgeon. All of the patients were evaluated both clinically and radiographic measurements before the procedure and each visit at the postoperative follow-up. Preoperative and postoperative X-ray imaging was performed before the procedure and at follow-up to assess the correlation with the clinical outcome. Radiological measurements and clinical outcomes were recorded to establish a relationship between the radiographic parameters and clinical outcome of this procedure. All patients had at least 2 years of follow-up.ResultsThe mean VAS score of back pain decreased significantly (p < 0.05).ConclusionsOur data suggest that percutaneous interspinous devices are a good alternative to treat LSS. The device offers significant decrease in back pain, leg pain and ODI score with 2-year lasting relief from symptoms. The increased intervertebral foramenal space explains the improvement of leg pain, but the mechanism of back pain relief remains unclear. A very weak correlation between the radiographic changes and improvement of pain was found.

Epidural and Intradural Cement Leakage following Percutaneous Vertebroplasty: A Case Report

A 48-year-old woman presented with severe bilateral leg pain, urinary incontinence, and paraparesis following vertebroplasty in another hospital 15 days earlier. Computed tomography and magnetic resonance imaging showed blocks of epidural and intradural cement from T12 to L1 with neurological compression. She underwent corpectomy of L1 and removal of extradural cement, followed by anterior reconstruction with an expandable cage and dual rodscrew construct (Kaneda system). Postoperatively, the patient had minimal improvement in leg pain and neurological deficit. Computed tomographic myelography was therefore performed and revealed complete blockage, which is suspected to be due to intradural cement leakage. The patient underwent posterior durotomy and removal of the cement. Postoperatively, the patient reported immediate pain relief. Her neurological status gradually improved over months. At the 2-year follow-up, the patient was able to walk with support and to perform activities of daily living and had regained her urinary function.