Laminectomy Patients Research Articles

Preemptive Local Infiltration of 0.5% Levobupivacaine HCl vs 0.5% Ropivacaine HCl for Postoperative Pain Control in Lumbar Laminectomy Patients

Preemptive Local Infiltration of 0.5% Levobupivacaine HCl vs 0.5% Ropivacaine HCl for Postoperative Pain Control in Lumbar Laminectomy Patients

Minimising costs in spinal surgery: is group & save testing justified in lumbar decompression surgery?

Lumbar microdiscectomy and laminectomy are two of the most common neurosurgical procedures performed worldwide. Current practice still sees pre-operative group and save testing prior to this surgery. The aim of this study was to determine the need for pre-operative group and save and post-operative blood checks. Patient archives were reviewed to identify those undergoing primary elective lumbar decompression surgery at the Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK. Hematology results before and after surgery, whether group and save was carried out, and blood transfusion requirements, if any, were collected. A total of 200 patients in total were included. Ninety-one percent of microdiscectomy patients and 95% of laminectomy patients underwent group and save testing prior to surgery. No patients received a transfusion as a result of their procedure. The mean hemoglobin drop after surgery was 11 g/L for the microdiscectomy group and 17 g/L for the laminectomy group. Our findings strongly suggest that pre-operative group and save is unnecessary in lumbar microdiscectomy and laminectomy. As such, we support the abandonment of routine pre-operative group and save and post-operative blood checks, with significant cost saving effects. However, O negative blood should always be available in case of major peri-operative bleeding.

Comparison of intraoperative blood loss during spinal surgery using either remifentanil or fentanyl as an adjuvant to general anesthesia

BackgroundRemifentanil enhances intraoperative hemodynamic stability, suggesting that it may decrease intraoperative blood loss when included as an adjuvant to general anesthesia. This retrospective study compared intraoperative blood loss during spinal surgery in patients administered either remifentanil or fentanyl as an opioid adjuvant.MethodsWe reviewed clinical and surgical data from 64 consecutive laminoplasty or laminectomy patients treated at National Hospital Organization Zentsuji Hospital between April 2010 and March 2011. Patients received either remifentanil (n = 35) or fentanyl (n = 29) as an opioid analgesic during general anesthesia. In addition to intraoperative blood loss, indices of hemodynamic stability, including heart rate as well as systolic, mean, and diastolic blood pressure (BP), were compared over the entire perioperative period between remifentanil and fentanyl groups.ResultsThe remifentanil group exhibited significantly lower intraoperative arterial BP than the fentanyl group. Intraoperative blood loss was also significantly lower in the remifentanil group (125 ± 67 mL vs. 165 ± 82 mL, P = 0.035).ConclusionsIntraoperative blood loss during spinal surgery was decreased in patients who received remifentanil as an opioid adjuvant, possibly because of lower intraoperative BP. A larger-scale prospective randomized controlled trial is warranted to confirm our results and to test whether remifentanil can decrease intraoperative blood loss during other surgical procedures.

Elevated preoperative blood pressure predicts the intraoperative loss of SSEP neuromonitoring signals during spinal surgery

Intraoperative neuromonitoring of somatosensory evoked potentials (SSEPs) can allow identification of evolving neurologic deficit. However, SSEP deterioration is not always associated with postoperative deficit. Transient physiologic changes, including a decrease in blood pressure (BP), can result in signal deterioration, defined as a decrease in waveform amplitude of[50 %seen without neurologic deficit. This study examines the relationship between intraoperative BP decrease and SSEP neuromonitoring to determine whether hypertensive patients are more prone to decreases in BP and if such BP declines are associated with signal loss. We conducted a retrospective review of 43 lumbar laminectomy patients at Mount Sinai. Patients were categorized based on whether they had a previous hypertension diagnosis and if they presented with a first systolic BP of greater than 140 mmHg in the admission area on the morning of surgery, two groups that were not mutually exclusive. We measured BP drop by calculating fractional mean arterial pressure (fMAP, lowest MAP/baseline MAP) and change in BP.We identified patients' SSEP tracings in which signal amplitude decreased[50 %. After dividing patients' recording times into 5-min epochs, we calculated median MAP and whether SSEPs deteriorated in each epoch. We compared the likelihood of signal loss in hypertensives to patients presenting with elevated BP, calculating the odds ratio. Elevated BP prior to surgery is associated with lower fMAP (p = 0.007) and a larger intraoperative decrease in BP (p\0.001).A diagnosis of hypertension is not associated with lower fMAP orBP drop. Lower epoch fMAPis associated with signal loss (p = 0.0026). While the presence of preoperative elevated BP predicts SSEP abnormality (p = 0.0039), a diagnosis of hypertension does not. Elevated BP, not a hypertension diagnosis, is associated with intraoperative loss of SSEP signals. This effect of elevated BP on SSEPs may be due to the larger associated intraoperative BP decline.

Interspinous device versus laminectomy for lumbar spinal stenosis: a comparative effectiveness study

Background contextCurrently no studies directly compare effectiveness between interspinous devices (IDs) and laminectomy in lumbar spinal stenosis (LSS) patients. PurposeTo compare reoperations, complications, and costs between LSS patients undergoing ID placement versus laminectomy. Study designRetrospective comparative study. Patient sampleThe MarketScan database (2007–2009) was queried for adults with LSS undergoing ID placement as a primary inpatient procedure. Outcome measuresReoperation rates, complication rates, and costs. MethodsEach ID patient was matched with a laminectomy patient using propensity score matching. Reoperations, complications, and costs were analyzed in patients with at least 18 months postoperative follow-up. The authors did not receive funding from any external sources for this study. ResultsAmong 498 inpatients that underwent ID placement between 2007 and 2009; the average age was 73 years. The cumulative reoperation rates after ID at 12 and 18 months were 21% and 23%, respectively. The average inpatient hospitalization lasted 1.6 days with an associated cost of $17,432. Two propensity-matched cohorts of 174 patients that had undergone ID versus laminectomy were analyzed. Longer length of stay was observed in the laminectomy cohort (2.5 days vs. 1.6 days, p<.0001), whereas ID patients accrued higher costs at index hospitalization ($17,674 vs. $12,670, p=.0001). Index hospitalization (7.5% vs. 3.5%, p=.099) and 90-day (9.2% vs. 3.5%, p=.028) complications were higher in the laminectomy cohort compared with the ID cohort. The ID patients had significantly higher reoperation rates than laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p=.026) and incurred higher cumulative costs than laminectomy patients at 12 months follow-up ($39,173 vs. $34,324, p=.289). ConclusionsTwelve-month reoperation rates and index hospitalization costs were significantly higher among patients who underwent ID compared with laminectomy for LSS.

Serum Procalcitonin and Neutrophil Toxic Granules Guided Management of Post-Operative &amp;lt;i&amp;gt;K. pneumoniae&amp;lt;/i&amp;gt; Septic-Shock in Laminectomy—A Case Report

Introduction: We still rely on clinical diagnosis for initiating empirical antibiotic therapy and await blood culture for confirmation of infection, species identification and drug sensitivity. Differential blood cell count (WBC and neutrophils) and recording of toxic granules in the neutrophils are established methods for indirect diagnosis of infection though they are not used in the diagnosis of sepsis per se. Serum Procalcitonin is considered as a good biomarker in the management of sepsis. Materials and Methods: Whole blood and serum were used for laboratory analysis. We have combined the detection of toxic granules in the peripheral blood smear and serum PCT levels for diagnosis and monitoring the recovery of a patient with septic shock. A 63 year old laminectomy patient was transferred 2 days after the surgery to our hospital with several co-morbidities and complications. He was in septic shock and was put on Continuous Renal Replacement Therapy, with ionotropic support and IV fluids via nasogastric feeding and administration of Activated Protein C. Blood culture and daily measurements of serum Procalcitonin, differential blood cells count, and observation of toxic granules in neutrophils were done. Results: The blood culture showed infection due to K. pneumoniae resistant to carbapenems. WBC and Neutrophil counts were quite variable and showed incoherent response to treatment. Serum PCT was 24.57 ng/mL on the next day of admission and it peaked at 30.2 ng/mL on day 3. Its level started decreasing from the 4th day. Toxic granules disappeared when serum PCT levels reached < 1 ng/mL. The patient responded well to treatment and he was discharged on the 16th day upon request. Conclusion: This case is presented as an example of managing sepsis with a combination of a conventional hematology marker and a modern biomarker. Resource poor hospitals with inadequate microbiology services, may evaluate and use these two biomarkers not only for the total management of sepsis but also to reduce the cost of critical care.

Comparison of efficacy of dexketoprofen versus paracetamol on postoperative pain and morphine consumption in laminectomy patients

The aim of this prospective randomized, double-blind study was to evaluate the analgesic efficacy and opioid-sparing effects of preemptive single dose of dexketoprofen trometamol in comparison with that of paracetamol or placebo for elective lumbar disc surgery, over a 24-hour (h) investigation period. After institutional approval and informed consent had been obtained, 75 patients scheduled for single level lumbar disc surgery were randomly allocated into three equal groups. Patients received oral dexketoprofen 25 mg (Group D), 500 mg paracetamol (Group P) or placebo tablets (Group C) 30 minutes (min) before induction of standard anesthesia. Patient-controlled analgesia was supplied postoperatively using morphine. Hemodynamics, visual analogue scale (VAS), sedation score, morphine consumption, and side effects were recorded every 15 min in the first hour and at 2, 6 and 24 h after surgery. The mean pain scores were similar among groups (p>0.05). The cumulative (SD) 24-h morphine consumption was 28.1 mg, 40.6 mg, and 43.6 mg for Groups D, P and C, respectively. The amount of morphine use at 2, 6 and 24 h was significantly lower in Group D (p<0.006). Hemodynamic parameters, sedation scores and side effects did not differ among the groups (p>0.05). The study demonstrated that preemptive dexketoprofen trometamol 25 mg is associated with a decrease of up to 35% in morphine consumption compared with placebo over the first 24 h following lumbar disc surgery; however, paracetamol 500 mg did not show the expected opioid-sparing effect comparatively.

In a quandary about cauda equina syndrome?

A: The term cauda equina can be literally translated as "the horse's tail." A bundle of nerve roots that constitutes the cauda equina begins below the level of the spinal cord termination, usually between the first and second lumbar vertebra. CES is rare, occurs equally in men and women, and isn't age specific. Occurring traumatically or atraumatically, CES may result from any lesion that compresses the cauda equina nerve roots, which can occur from inflammation, direct compression, ischemia, or venous congestion. The most common cause is lumbar intervertebral disk herniation. Other causes include traumatic injury, abscess, spinal anesthesia, tumor ankylosing spondylitis, inferior vena cava thrombosis, lymphoma, and sarcoidosis. The nerve roots of the cauda equina are susceptible to injury and increased permeability, which may then lead to edema formation even with the slightest injury.Figure: Q:I just received a post-op laminectomy patient with cauda equina syndrome (CES). What is it?CES has no definite criteria for diagnosis. Diagnosis includes your patient's clinical history, physical exam, and radiologic testing. The patient usually presents with low back pain that's different than common lumbar strain, unilateral or bilateral lower extremity motor or sensory abnormality, recent onset of bladder dysfunction (such as bladder incontinence or retention), bowel incontinence, perineal anesthesia, pain in the legs or radiation to the legs, reflex abnormalities (loss or diminished), pain localized to the low back, and poor sphincter tone. To prevent and avoid lifelong disability, a careful examination and history taking is crucial. Imaging studies that are useful in identifying CES are computed tomography scan, magnetic resonance imaging, and computed tomography myelography. Catheterization for residual urine volume may reveal urinary retention, which suggests a neurogenic bladder. Patients who have suspected CES are referred immediately for a neurologic evaluation. After CES is diagnosed, surgical intervention may be indicated if compression is due to disk herniation. Usually, surgical decompression is recommended within 24 to 48 hours of symptom onset to avoid permanent neurologic damage. Complications your patient may experience include residual weakness, incontinence, impotence, and sensory abnormalities. You can help your patient travel the road of recovery by offering appropriate education regarding CES, referring him to support groups, and allowing him and his family to voice their concerns about this potentially life-altering condition.

Conservative management of an acute spontaneous holocord epidural hemorrhage in a hemophiliac infant

Central nervous system hemorrhages are an uncommon but severe complication of hemophilia, occurring in only 2-8% of children with hemophilia. Less than 10% of these CNS hemorrhages are intraspinal. The authors report on their care of an infant with hemophilia A who presented with irritability, meningismus, and decreased spontaneous movement. These symptoms prompted imaging studies, which revealed a spinal epidural hematoma (SEH) extending from C-1 through the cauda equina. The boy was treated with factor replacement and close monitoring. Repeat radiographic imaging 14 days later demonstrated complete resolution, and the patient had returned to his normal baseline status. A literature review in the modern treatment era revealed 24 cases of SEH in children with hemophilia. Of these 24 cases, 11 underwent laminectomy and 13 received conservative treatment. All conservatively treated patients, 5 of whom had presented with weakness, experienced a full recovery. Of the 11 laminectomy patients, 10 presented with weakness and all but 3 experienced full neurological improvement. These 3 patients were notable for having previously undiagnosed hemophilia. An increased index of suspicion facilitates the essential management features of prompt diagnosis and correction of coagulopathies in children who present with SEHs. The authors apply a multidisciplinary approach involving a pediatric hematologist, neurosurgeon, and pediatric intensive care unit to ensure timely correction of the coagulation disorder, maintenance of adequate factor levels, and close hemodynamic and neurological monitoring. Observation with aggressive correction of coagulopathy is a reasonable treatment choice for hemophilic patients presenting with SEH and a stable neurological examination.

Tubular Microsurgery for Lumbar Discectomies and Laminectomies in Obese Patients

This is a retrospective single-center case study involving 115 obese and nonobese patients who underwent minimally invasive lumbar surgery between 2004 and 2007. The purpose of this study was to evaluate the effect of minimally invasive spinal surgery in obese and nonobese patients by operative results and patient outcomes. Spinal surgery in obese patients is associated with increased complications, blood loss, and operative times. The potential benefits of minimally invasive lumbar surgery in obese patients are discussed. All patients underwent 1-level lumbar microdiscectomy or laminectomy using tubular retractors. Data were collected on patient demographics, comorbidities, smoking habits, operative results, and clinical outcomes, and compared for obese and nonobese patients. Operative results included operative times, blood loss, length of stay, and perioperative complications. Clinical outcomes were assessed by using pre- and postoperative visual analog scale and Macnab outcome criteria at most recent follow-up. In this study, 31% of 115 patients were classified as obese. Obese patients tended to undergo surgery at a younger age. Obesity, comorbidities, and age did not have an impact on patient outcome at a mean follow-up of 15.9 months. No significant differences were seen between obese versus nonobese patients in terms of incision lengths, operative time, blood loss, and complication rates. In obese patients, all parameters and operative results compared favorably to reported historical results of patients undergoing open lumbar surgery. Overall, favorable outcome was seen in 92% and 84% of obese and nonobese lumbar microdiscectomy patients, respectively, and in 75% of laminectomy patients. Postoperative visual analog scale did not show any significant difference. This is the first study comparing operative results from tubular microsurgery between obese and nonobese patients. No major differences were detected in outcome, operative and perioperative data including complication rates. With tubular microsurgery, obese patients experienced the same or equally beneficial outcome, compared to nonobese patients, while incision lengths, blood loss, operative times, and length of stay were less when compared to open procedures. Other comorbidities and age had no significant impact on perioperative complications and clinical outcome.

Plasma Levels of Vascular Endothelial Growth Factor After Treatment for Cerebral Arteriovenous Malformations

The role of abnormal angiogenesis in the formation and progression of cerebral arteriovenous malformations (AVMs) is unclear. Previous studies have demonstrated increased local expression of vascular endothelial growth factor (VEGF) in AVM tissue and increased circulating levels of VEGF in AVM patients. We sought to further investigate the role of VEGF in AVM pathophysiology by examining changes in plasma VEGF levels in patients undergoing treatment for AVMs. Three serial blood samples were obtained from 13 AVM patients undergoing treatment: (1) before any treatment, (2) 24 hours postresection, and (3) 30 days postresection. Plasma VEGF concentrations were measured via commercially available enzyme-linked immunosorbent assay (ELISA). For controls, blood samples were obtained from 29 lumbar laminectomy patients. The mean plasma VEGF level in AVM patients at baseline was 36.08+/-13.02 pg/mL, significantly lower than that of the control group (80.52+/-14.02 pg/mL, P=0.028). Twenty-four hours postresection, plasma VEGF levels dropped to 20.09+/-4.54 pg/mL, then increased to 66.81+/-26.45 pg/mL 30 days later (P=0.048). The mean plasma VEGF concentration 30 days after resection was no longer significantly different from the control group (P=0.33). Plasma VEGF levels in 13 AVM patients were unexpectedly lower than controls, dropped early after AVM resection, then significantly increased 30 days later. These results support the key role of abnormal angiogenesis in AVM pathophysiology and suggest that a disruption in systemic VEGF expression may contribute to the natural history of these lesions.

Pre-emptive infiltration of levobupivacaine is superior to at-closure administration in lumbar laminectomy patients

This is a prospective, randomized, controlled trial that compared the efficacy of different protocols of local tissue infiltration with levobupivacaine or levobupivacaine-methylprednisolone at the surgical site for pain relief after lumbar discectomy. The objective of the study was to determine the efficacy of preemptive wound infiltration with levobupivacaine and levobupivacaine-methylprednisolone at the surgical site for pain relief. Patients usually suffer significant pain after lumbar discectomy. Wound infiltration with local anesthetics with or without corticosteroids is one method to address this. A total of 100 patients were randomly allocated to five equal groups as follows: Group I had the musculus multifidi near the operated level infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone just before wound closure; Group II had the same region infiltrated with 30 mL 0.25% levobupivacaine alone before closure; Group III had this region infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone before the incision was made; in Group IV this region was infiltrated with 30 mL 0.25% levobupivacaine alone before incision; and in Group C (controls) this region was infiltrated with 30 mL 0.9% NaCl just before wound closure. Demographics, vital signs, postoperative pain scores and morphine usage were recorded. All four treatment groups showed significantly better results than the control group for most parameters. The treated groups had lower parenteral opioid requirements after surgery, lower incidences of nausea and shorter hospital stays. Further, the data indicate that, compared with infiltration of these drugs at wound closure, preemptive injection of levobupivacaine or levobupivacaine-methylprednisolone into the muscle near the operative site provides more effective analgesia after lumbar discectomy. Our data suggest that preemptive infiltration of the wound site with levobupivacaine alone or combined with methylprednisolone provides effective pain control with reduced opiate dose after unilateral lumbar discectomy.

Comparison of Techniques for Decompressive Lumbar Laminectomy: the Minimally Invasive versus the “Classic” Open Approach

Decompressive laminectomy offers an effective surgical treatment of lumbar spinal stenosis. The purpose of this study was to compare the elements of treatment commonly associated with successful outcomes in the assessment of laminectomies - operating room times, estimated blood loss, length of stay, and complications - of the minimally invasive and open approach laminectomies. We retrospectively reviewed the medical records and relevant imaging of 126 patients who underwent surgical decompression for lumbar stenosis. Thirty-eight patients underwent bilateral decompression via a unilateral minimally invasive technique, while 88 patients underwent bilateral decompression via a standard open technique. A chart review was performed to determine intraoperative blood loss, length of operative time, length of hospital stay, and number and nature of complications. The minimally invasive lumbar laminectomy (MID) patients had shorter operating room times, less estimated blood loss, shorter length of stay, and fewer complications. Bilateral decompression of lumbar spinal stenosis via a unilateral approach involves shorter operating times and less blood loss, less muscle dissection, fewer and less severe complications, and better mobility in the immediate postoperative period than open decompressive techniques. In addition, this technique is very similar to the commonly performed microendoscopic discectomy and is easily mastered over time.

Post-carotid endarterectomy neurocognitive decline is associated with cerebral blood flow asymmetry on post-operative magnetic resonance perfusion brain scans

Objective: Up to 25% of patients experience subtle declines in post-operative neurocognitive function following, otherwise uncomplicated, carotid endarterectomy (CEA). We sought to determine if post-CEA neurocognitive deficits are associated with cerebral blood flow (CBF) abnormalities on post-operative MR perfusion brain scans.Methods: We enrolled 22 CEA patients to undergo a battery of neuropsychometric tests pre-operatively and on post-operative day 1 (POD 1). Neurocognitive dysfunction was defined as a two standard deviation decline in performance in comparison to a similarly aged control group of lumbar laminectomy patients. All patients received MR perfusion brain scans on POD 1 that were analysed for asymmetries in CBF distribution. One patient experienced a transient ischemic attack within 24 hours before the procedure and was excluded from our analysis.Results: Twenty-nine percent of CEA patients demonstrated neurocognitive dysfunction on POD 1. One hundred percent of those patients with cognitive deficits demonstrated CBF asymmetry, in contrast to only 27% of those patients without cognitive impairment. Post-CEA cognitive dysfunction was significantly associated with CBF abnormalities (RR=3.75, 95% CI: 1.62–8.67, p=0.004).Conclusion: Post-CEA neurocognitive dysfunction is significantly associated with post-operative CBF asymmetry. These results support the hypothesis that post-CEA cognitive impairment is caused by cerebral hemodynamic changes. Further work exploring the relationship between CBF and post-CEA cognitive dysfunction is needed.

Risk Factors for Surgical Site Infection Complicating Laminectomy

To examine risk factors for surgical site infection (SSI) following spinal surgery and to analyze the associations between a surgeon's years of operating experience and surgical specialty and patients' SSI risk. Case-control study. A tertiary care facility and a community hospital in Durham, North Carolina. Each case patient who developed an SSI complicating laminectomy was matched with 2 noninfected control patients by hospital, year of surgery, and National Nosocomial Infection Surveillance System risk index score. Forty-one case patients with SSI complicating laminectomy and 82 matched control patients were analyzed. Nonwhite race, diabetes and an elevated body mass index (BMI) were more common among case patients than among control patients. Subjects with a BMI greater than 35 were more likely to undergo a prolonged procedure, compared with case patients who had a BMI of 35 or less. The SSI rate for patients operated on by neurosurgeons was 28%, compared with 43% for patients operated on by orthopedic surgeons (odds ratio [OR], 0.5; P=.12). The number of years of operating experience were not associated with SSI risk. Multivariate analysis revealed diabetes (OR, 4.2 [95% confidence interval {CI}, 1.1-16.3]; P=.04), BMI greater than 35 (OR, 7.1 [95% CI, 1.8-28.3]; P=.005), and laminectomy at a level other than cervical (OR, 6.7 [95% CI, 1.4-33.3]; P=.02) as independent risk factors for SSI following laminectomy. Diabetes, obesity, and laminectomy at a level other than cervical are independent risk factors for SSI following laminectomy. Preoperative weight loss and tight perioperative control of blood glucose levels may reduce the risk of SSI in laminectomy patients.

Transforaminal Epidural Blood Patch

Spinal headache is an occasional, but painful complication of epidural injection procedures due to dural puncture that allows leakage of CSF from the thecal sac, thereby reducing intracranial pressure. In the event of failure of conservative management, (e.g. abdominal binder, fluids, acetaminophen), an epidural blood patch is often used. This case report describes a patient with spinal headache after a transforaminal selective epidural injection in a post laminectomy patient that was treated with a transforaminal epidural blood patch after the failure of conservative management. The patient underwent left transforaminal epidural injections at L5 and S1 for management of chronic low back pain secondary to post laminectomy syndrome. Three days later, the patient presented with a severe post lumbar puncture headache and failed to respond to conservative management. Interlaminar epidural approach for blood patch was not feasible secondary to prior laminectomy. Transforaminal epidural blood patch was performed utilizing 2 mL of autologous blood at each of the two sites. The patient recovered well without headache. In cases, with inability to perform interlaminar blood patch, a transforaminal approach may be considered.

X STOP versus Decompression for Neurogenic Claudication: Economic and Clinical Analysis

Introduction: The X STOP is the first Interspinous Process Decompression (IPD) device that is proven to be superior to nonoperative therapy in patients with neurogenic intermittent claudication secondary to lumbar spinal stenosis (LSS) in a multicenter randomized study at 1 and 2 years. The clinical success rate in the X STOP IPD group was comparable to that reported for laminectomy. The goal of the current study was to compare the clinical effectiveness and direct hospital costs of IPD with the X STOP implant to those of laminectomy in patients with LSS. Methods: Thirty patients with LSS treated surgically were matched for age and length of follow-up. Eighteen of thirty patients had X STOP implantation and twelve of thirty had laminectomy. The pre and post-operative Oswestry scores and hospital charges for the two groups were compared. An absolute improvement of 15 ODI points was selected to define an individual patient success. Results: Twelve of 18 X STOP patients (67%) were treated at one level and six of 18 (33%) at two levels. Three of 12 laminectomy patients (25%) were treated at one level and nine of 12 (75%) at two levels. The average age was 68 years (SD 12.5) for X STOP patients and 69 years (SD 7.9) for laminectomy patients. Six of the 18 X STOP patients (33%) had grade I degenerative spondylolysthesis at the treated level versus two of 12 patients (17%) in the laminectomy group. The minimum follow-up was 45 months in the X STOP group and 43 months in the laminectomy group. The average follow-up was 51 months in the X STOP group (SD 5.3) and 52 months in the laminectomy group (SD 5.3). Pre-operative average ODI score in the X STOP group was 45 vs. 36 in the laminectomy group (p>0.1560). Post-operative average ODI score in the X STOP group was 15 and 24 in the laminectomy group (p>0.1159). The absolute ODI change was 29 points for the X STOP group, and 12 points for the laminectomy group (p<0.0186). The relative ODI change was 64% for the X STOP group, and 29% for the laminectomy group (p<0.0369). Based on the selected success criterion (ODI improvement of at least 15 points), fourteen of 18 (78%) X STOP procedures were considered successful and four of 12 (33%) laminectomy procedures were deemed successful (p<0.0243). Average direct hospital costs for 1 level X STOP and 1 level laminectomy group were $15,980 and $45,302 respectively (p<0.0001). Average hospital costs for 2 level X STOP and 2 level laminectomy groups were $25,618 and $46,752 respectively (p<0.0010). The main savings in the X STOP group (cost drivers) were in OR costs (shorter operative time), hospital charges (X STOP is an outpatient procedure) and anesthesia charges (X STOP is placed under local/ MAC anesthesia). Discussion: The present study demonstrated that X STOP IPD is clinically at least as effective as laminectomy at 4 year followup based on the ODI scores. The subset of patients with degenerative instability (6 of 18) had equally good results with X STOP treatment and avoided fusion. The somewhat lower scores in the laminectomy group at 4 years could be due to the limited sample size and known deterioration of the success of surgical decompression with time. IPD with the X STOP implant was associated with significantly smaller direct hospital costs compared to laminectomy for the surgical treatment of lumbar spinal stenosis. A single level X STOP IPD is about $29,000 less expensive than a single level laminectomy, and a double level X STOP IPD is about $21,000 less expensive than double level laminectomy. Summary: IPD with X STOP device for the treatment of LSS is clinically at least as effective as standard laminectomy at 4 years post-operatively and provides substantial direct cost savings compared to decompressive surgery. X STOP versus Decompression for Neurogenic Claudication: Economic and Clinical Analysis

Contribution of Facet Joints to Chronic Low Back Pain in Postlumbar Laminectomy Syndrome: A Controlled Comparative Prevalence Evaluation

Postlumbar laminectomy syndrome, or pain following operative procedures of the lumbar spine, is increasingly a common entity in modern medicine. Multiple causes proposed for recurrence of pain after lumbar laminectomy are: epidural fibrosis, recurrent disc herniation, instability, and facet joints. Even though the prevalence of persistent low back pain secondary to the involvement of lumbosacral facet joints has been described in controlled studies from 15% to 45%, the prevalence of facet joint mediated pain in postlumbar laminectomy syndrome has not been studied. This prospective, randomized, controlled comparative evaluation was performed to determine the prevalence of facet joint mediated pain in persistent low back pain in postlumbar laminectomy patients with a comparative non-surgical group. One hundred patients with fifty patients in each group were randomly assigned with group I consisting of fifty patients without history of previous surgery and group II consisting of fifty patients with history of previous surgery. Results showed that the prevalence of facet joint mediated pain in non-surgical patients was 44% compared to 32% in post surgical patients determined by comparative controlled local anesthetic blocks utilizing lidocaine and bupivacaine. This study also showed a false positive rate of 36% in non-surgical group and 24% in post-surgical group. In conclusion, this study shows that facet joint mediated symptomatology in chronic low back pain is prevalent, both in non-surgical as well as post-surgical patients even though prevalence was somewhat higher in the non-surgical group compared to post-surgical group.

A Critical Review of Cervical Laminoplasty

Purpose Laminoplasty was developed in the 1970s as an alternative technique to laminectomy in treating patients with ossified posterior longitudinal ligaments or cervical spondylosis. The proposed advantage was expansion of the spinal canal while preserving spinal stability and preventing the formation of postlaminectomy kyphosis. Methods A meta-analysis of the laminoplasty literature was performed. Outcome measures included postoperative cervical alignment, change in range of motion (ROM), neurologic outcome, and complications. Results Seventy-one studies comprising more than 2000 patients were reviewed. All studies were retrospective and nonrandomized. There was worsening of cervical alignment after laminoplasty in 35% of patients. Ten percent of long-term follow-up patients developed postlaminoplasty kyphosis. There was significant progressive decrease in cervical ROM after laminoplasty, with a mean decrease of 50%. In long-term follow-up studies, the ROMs of laminoplasty patients paralleled those of laminectomy patients. The mean recovery rate was 55% (range: 20%–80%), with approximately 80% of patients improving. There was no difference in neurologic outcome based on laminoplasty versus laminectomy or on the different types of laminoplasty techniques used. Reporting of complications was inconsistent. There was no evidence of postlaminectomy membrane leading to neurologic compromise or deterioration. Postoperative C5 nerve root dysfunction was reported by a few studies, and the incidence was approximately 8%. Axial neck pain after laminoplasty was noted in 6% to 60% of patients. Conclusions There is no benefit of laminoplasty over laminectomy and fusion in terms of preservation of spinal alignment, kyphotic deformity, and neurologic outcome, which we identify after this review.

Spinal Deformity After Selective Dorsal Rhizotomy in Ambulatory Patients With Cerebral Palsy

Thirty-four patients with ambulatory spastic diplegia (ages 10–19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60°. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5° in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.