Leg Pain Scores Research Articles

Risk Factors for Poor Outcomes Following Minimally Invasive Discectomy: A Post Hoc Subgroup Analysis of 2-Year Follow-up Prospective Data.

ObjectiveA post hoc subgroup analysis of prospectively collected data from a randomized controlled trial was conducted to identify risk factors related to poor outcomes in patients who underwent minimally invasive discectomy. MethodsPatients were divided into satisfied and dissatisfied subgroups based on Oswestry Disability Index (ODI), visual analogue scale (VAS) back pain score (VAS-back) and leg pain score (VAS-leg) at short-term and midterm follow-up according to the patient acceptable symptom state threshold. Demographic characteristics, radiographic parameters, and clinical outcomes between the satisfied and dissatisfied subgroups were compared using univariate and multivariate analysis. ResultsA total of 222 patients (92.1%) completed 2-year follow-up, and the postoperative ODI, VAS-back, and VAS-leg were significantly improved after surgery as compared to preoperatively. Multivariate analysis indicated older age (p=0.026), lateral recess stenosis (p=0.046), and lower baseline ODI (p=0.027) were related to poor short-term functional improvement. Higher baseline VAS-back (p=0.048) was associated with poor short-term relief of back pain, while absence of decreased sensation (p=0.019) and far-lateral disc herniation (p=0.004) were associated with poorer short-term relief of leg pain. Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement (p=0.003) and relief of back pain (p=0.031). Disc protrusion (p=0.036) predicted poorer relief of back pain at midterm follow-up. ConclusionIn this study, several factors were identified to be predictive of poor surgical outcomes following minimally invasive discectomy. (ClinicalTrials.gov number: NCT01997086).

Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation

Background and study aimsMultiple surgical approaches have been studied and accepted for the removal of highly downward migrated lumbar disc herniation (LDH). Here, we investigated the efficacy and safety of full-endoscopic foraminoplasty for highly downward migrated LDH.Patients and methodsThirty-seven patients with highly down-migrated LDH treated by the full-endoscopic foraminoplasty between January 2018 and January 2020 were retrospectively investigated. Clinical parameters were evaluated preoperatively and 1, 6, and 12 months postoperatively, using pre- and post-operative Oswestry Disability Index (ODI) scores for functional improvement, visual analog scale (VAS) for leg and back pain, and modified MacNab criteria for patients satisfactory.ResultsThirty-seven patients with highly downward migrated LDH were successfully removed via the transforaminal full-endoscopic discectomy. The average VAS back and leg pain scores were significantly reduced from 7.41 ± 1.17 and 8.68 ± 1.06 before operation to 3.14 ± 0.89 and 2.70 ± 0.46 at postoperative 1 month, and 1.76 ± 0.59 and 0.92 ± 0.28 at postoperative 12 months, respectively (P < 0.05). The average ODI scores were reduced from 92.86 ± 6.41 to 15.30 ± 4.43 at postoperative 1 month, and 9.81 ± 3.24 at postoperative 12 months (P < 0.05). Based on the modifed MacNab criteria, 36 out of 37 patients (97.30%) were rated as excellent or good outcomes.ConclusionThe full-endoscopic foraminoplasty can be used successfully for surgical removal of high grade down-migrated LDH, and it could serve as an efficient alternative technique for patients with highly downward migrated LDH.

Efficacy comparison of unilateral biportal endoscopic decompression and extended interlaminar fenestration for lumbar lateral recess stenosis

Objective: To analyze and compare the clinical efficacy of unilateral biportal endoscopic(UBE) decompression and extended interlaminar fenestration for lumbar lateral recess stenosis. Methods: A retrospective analysis of 103 patients treated with UBE decompression or extended interlaminar fenestration for lumbar lateral recess stenosis from July 2017 to June 2020 in the Second Hospital of Anhui Medical University was performed. Eighty patients aged 40 to 86 (63.2±9.8) years were included in this study, including 42 males and 38 females. Forty patients received UBE decompression (UBE group) and 40 patients received extended interlaminar fenestration (fenestration group). Operative time, length of incision, hospital stay and complications were recorded. The visual analogue scale (VAS) scores of low back pain and leg pain and Oswestry dysfunction index (ODI) scores were recorded preoperatively and at 1, 3 and 6 months after the operation and at the final follow-up, and the modified Macnab scale was used to evaluate the clinical efficacy at the final follow-up. Results: Patients in both groups successfully received lumbar lateral recess decompression and were followed up for (12.9±5.4) months in the UBE group and (14.9±3.5) months in the fenestration group, respectively. The operation time in the UBE group was (63.9±11.6) min, it was higher than that in the fenestration group ((54.1±9.2) min, P<0.001). The average incision length in the UBE group was (18.2±1.7) mm, it was lower than that in the fenestration group ((73.5±11.6) mm, P<0.001). Postoperative hospital stay in the UBE group was (4.1±2.2) d, it was lower than that in the fenestration group ((7.6±3.1) d, P<0.001). VAS scores of low back pain were improved after operation in both groups. Low back pain VAS scores of UBE group were lower than those in fenestration group at 1 and 3 months post operation (both P<0.05). The VAS scores of lower limb pain were improved after operation in both groups and there was no statistically significant difference between the two groups at postoperative 1, 3, 6 months after the operation and at the last follow-up (all P>0.05). ODI scores were improved after operation in both groups. ODI scores of UBE group were lower than those in fenestration group at postoperative 1 month and 3 months(both P<0.05). Intraoperative dural tear occurred in 2 cases(5.0%) in the UBE group and 1 case(2.5%) in the fenestration group, with no statistically significant difference between the two groups (P=0.556). According to the modified Macnab scale at the last follow-up, 35 cases were excellent, 3 cases were good, and 2 cases were fair in the UBE group, and 37 cases were excellent, 2 cases were good, and 1 case was fair in the open group. The difference was not statistically significant between the two groups (P=0.745). Conclusion: Compared with the extended interlaminar fenestration, UBE technique can not only reduce the early postoperative low back pain, shorten hospital stay, but also achieve the same long-term clinical efficacy with less trauma.

Predictors of long-term clinical outcomes in adult patients after lumbar total disc replacement: development and validation of a prediction model.

Long-term outcomes of single-level lumbar arthroplasty are understood to be very good, with the most recent Investigational Device Exemption (IDE) trial showing a < 5% reoperation rate at the close of the 7-year study. This post hoc analysis was conducted to determine whether specific patients from the activL IDE data set had better outcomes than the mean good outcome of the IDE trial, as well as to identify contributing factors that could be optimized in real-world use. Univariable and multivariable logistic regression models were developed using the randomized patient set (n = 283) from the activL trial and used to identify predictive factors and to derive risk equations. The models were internally validated using the randomized patient set and externally validated using the nonrandomized patient set (n = 52) from the activL trial. Predictive power was assessed using area under the receiver operating characteristic curve analysis. Two factors were significantly associated with achievement of better than the mean outcomes at 7 years. Randomization to receive the activL device was positively associated with better than the mean visual analog scale (VAS)-back pain and Oswestry Disability Index (ODI) scores, whereas preoperative narcotics use was negatively associated with better than the mean ODI score. Preoperative narcotics use was also negatively associated with return to unrestricted full-time work. Other preoperative factors associated with positive outcomes included unrestricted full-time work, working manual labor after index back injury, and decreasing disc height. Older age, greater VAS-leg pain score, greater ODI score, female sex, and working manual labor before back injury were identified as preoperative factors associated with negative outcomes. Preoperative BMI, VAS-back pain score, back pain duration ≥ 1 year, SF-36 physical component summary score, and recreational activity had no effect on outcomes. Lumbar total disc replacement for symptomatic single-level lumbar degenerative disc disease is a well-established option for improving long-term patient outcomes. Discontinuing narcotics use may further improve patient outcomes, as this analysis identified associations between no preoperative narcotics use and better ODI score relative to the mean score of the activL trial at 7 years and increased likelihood of return to work within 7 years. Other preoperative factors that may further improve outcomes included unrestricted full-time work, working manual labor despite back injury, sedentary work status before back injury, and randomization to receive the activL device. Tailoring patient care before total disc replacement may further improve patient outcomes.

Mental Health as a Predictor of Preoperative Expectations for Pain and Disability Following Lumbar Fusion

To evaluate impact of preoperative mental health on expectations in patients undergoing transforaminal, anterior, or lateral lumbar interbody fusion. Demographics, perioperative characteristics, duration of preoperative symptoms, and preoperative mental health scores were collected. Pain and disability were recorded using preoperative visual analog scale (VAS) for back and leg pain and Oswestry Disability Index scores. Patients' expectations were recorded. Preoperative mental health was recorded using Patient Health Questionnaire-9 (PHQ-9), 12-Item Short Form Health Survey (SF-12) mental component score (MCS), and Veterans RAND 12-Item Health Survey (VR-12) MCS. PHQ-9 scores were categorized by severity of depressive symptoms. Simple linear regression evaluated impact of preoperative mental health on patient expectations for pain and disability; multiple linear regression evaluated the same while accounting for preoperative scores. In 181 patients, PHQ-9 and increasing severity of depressive symptoms significantly predicted VAS back pain expectations (P ≤ 0.006); significance was lost after accounting for preoperative VAS back pain. All mental health outcomes significantly predicted VAS leg pain expectations (P ≤ 0.040); only PHQ-9 retained significance after accounting for preoperative VAS leg pain. All mental health scores significantly predicted ODI expectations (P < 0.001); none retained significance after accounting for preoperative ODI. PHQ-9, SF-12, and VR-12 significantly predicted all ODI domains except personal care and pain intensity (P ≤ 0.045). PHQ-9 significantly predicted patient expectations for lifting, walking, standing, sleeping, sex life, and social life. SF-12 MCS significantly predicted expectations for lifting, walking, standing, sleeping, and social life after accounting for preoperative domain scores. VR-12 MCS significantly predicted expectations for lifting, walking, standing, sleeping, sex life, and social life (P ≤0.050, all), even after accounting for preoperative scores. Mental health scores impact expectations regarding improvement in more active areas of a patient's life. Poor mental health scores may be associated with lower expectations for preoperative symptom improvement.

Ten-Year Outcomes of Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion in Patients With Single-Level Lumbar Spondylolisthesis.

A retrospective observational study. This study investigated the clinical and radiological results of minimally invasive (MI) versus open transforaminal lumbar interbody fusion (TLIF) in patients with single-level lumbar spondylolisthesis over a 10-year period. Few studies have compared 10-year follow-up outcomes between MI-TLIF and open TLIF. We retrospectively collected the outcome data of patients with single-level lumbar spondylolisthesis who underwent TLIF procedures using an MI (n = 108) or open (n = 53) approach. Fifty-two (48%) and 31 (58%) patients in the MI-TLIF and open TLIF groups, respectively, completed the 10-year follow-up. A primary clinical outcome included the Oswestry Disability Index (ODI) as well as visual analog scale (VAS) scores for back and leg pain at baseline and at 2, 5, and 10 years postoperatively. The radiographic fusion rate and incidence of secondary surgery due to adjacent segment disease were assessed at 2, 5, and 10 years postoperatively. Intraoperative blood loss and length of hospitalization were significantly lower in the MI-TLIF group than in the open TLIF group. At 2 years postoperatively, the ODI and VAS scores for back and leg pain were significantly lower in the MI-TLIF group than in the open TLIF group. No significant differences were found in VAS scores for back and leg pain or ODI scores between the two groups at 10 years postoperatively. Radiographic fusion rates and prevalence of secondary surgery for adjacent segment disease were not significantly different between the groups at 10 years postoperatively. Efficacy of MI-TLIF for patients with single-level lumbar spondylolisthesis is comparable to that of open TLIF over 10-years. However, MI-TLIF may have superior perioperative recovery and 2-year postoperative functional outcomes than open TLIF.Level of Evidence: 3.

Transforaminal Endoscopic Lumbar Discectomy with Foraminoplasty for Down-migrated Disc Herniation: A Single-center Observational Study

Objective: Full-endoscopic lumbar discectomy has evolved to be an alternative for the treatment of lumbar disc herniation. Regarding the techniques, the transforaminal approach remains the primary access. The indications of transforaminal endoscopic lumbar discectomy (TELD) have expanded following the evolution of the techniques, especially TELD with foraminoplasty. This study is to evaluate the efficacy of the TELD with foraminoplasty for downward migrated lumbar disc herniation.Methods: The authors conducted a retrospective study with prospectively collected data in a single center. The study enrolled patients with downward migrated lumbar disc herniation undergoing TELD with foraminoplasty from May 2009 to June 2018. All procedures were performed under local anesthesia. Patients' demographics, clinical outcomes, and satisfaction with surgery were recorded. Results: There were 126 patients included in the current study. The mean age was 50.7±17.4 years old. The leg pain and functional outcome scores significantly improved after the operation. There was no neurological deficit or iatrogenic instability requiring fusion surgery. The operation time was within 2 hours in most cases (92%). Thirteen patients reported minor complications, but symptoms were self-limited or responded to conservative treatment. The operation satisfied 94.4% of patients. Seven cases underwent revision surgery within six months due to recurrence.Conclusion: TELD with foraminoplasty under local anesthesia can be an alternative for downward migrated lumbar disc herniation. Nerve root irritation can be detected without intraoperative neurophysiological monitoring when the patient is awake during the procedures. The clinical outcomes were favorable and the risk of complication was low with the current technique.

Patient Satisfaction With Care Is Associated With Better Outcomes in Function and Pain 1 Year After Lumbar Spine Surgery.

There has been increasing interest in patient-reported experience measures (PREMs) to evaluate the patient experience and satisfaction with care. We conducted a prospective multicenter cohort study to determine any association between patients' satisfaction of care and their outcomes 1 year after lumbar spine surgery. Satisfaction with care was recorded through telephone interviews and a standardized questionnaire. Baseline data collection (300 patients) and 1-year follow-up (209 patients) were conducted through The Swedish National Register for Spine Surgery (Swespine). Exposures were patient experiences, health care professional (HCP) attitudes, shared decision-making, and overall satisfaction with care. Associations were evaluated using adjusted analysis of covariance (ANCOVA) models. Satisfaction with HCP attitudes was not associated with improvements at 1 year in Oswestry Disability Index (ODI) or back pain; however a significantly greater improvement in leg pain score was reported by patients who were highly satisfied (3.0 points) versus the moderate/low satisfaction group (1.3 points; P=0.008). For shared decision-making, high satisfaction was associated with significantly greater improvements, as compared to moderate/low satisfaction, in ODI (20 vs 11 points; P=0.001), back pain (2.6 vs 1.7 points; P=0.05), and leg pain (3.2 vs 1.9 points, P=0.007). Similarly, high overall satisfaction with care was associated with significantly greater improvements in ODI (18 vs 10 points; P=0.02), back pain (3.2 vs 0.6 points; P<0.001), and leg pain (2.6 vs 1.1 points; P=0.009). Findings indicate that shared decision-making on perioperative care and patients' overall satisfaction with care were associated with better health outcomes 1 year after lumbar spine surgery.

Laterally placed expandable interbody spacers with and without adjustable lordosis improve patient outcomes: A preliminary one-year chart review

Background/objectivesMinimally invasive lateral lumbar interbody fusion (MIS LLIF) has been employed to treat degenerative disc disease, with reduced complication profiles in comparison to other open anterior and posterior techniques. The technique permits the use of larger, coronal-spanning interbody spacers to restore height and alignment. However, large static spacers have historically been associated with iatrogenic complications during trialing and insertion. Developments in expandable technology have the potential for incrementally larger increases in both height and lordosis in a controlled expansion in situ, minimizing endplate violation. However, further clinical and radiographic data are needed to investigate the effect of expansion technology. MethodsA retrospective, single-surgeon chart review was performed on 103 consecutive patients, all of whom underwent MIS LLIF surgery at 1–2 contiguous level(s) with expandable spacers [66/103 patients were implanted with lordotically actuated (adjustable lordosis) spacers, and 37/103 with non-adjustable lordosis spacers]. Clinical and radiographic functional outcomes were collected and compared at both preoperative and postoperative time points up to 12-month follow-up. Parametric and nonparametric tests were utilized when they were appropriate, with a P value < 0.05 being significant. ResultsOne-hundred twenty-five levels were instrumented on 103 consecutive cases. Average age was 58.2 ± 12.1 years; 42.1% (45/107) were female; 78.6% (81/103) were 1-level cases; 21.4% (22/103) were 2-level cases; 44.8% (56/125) were performed at L4–L5 and 34.4% (43/125) at L3–4. Average estimated blood loss was 24.6 ± 12.3cc. Mean operative time was 61.0 ± 19.1 min, and mean fluoroscopic time was 28.2 ± 14.6 s. Visual Analog Scale (VAS) back and leg pain scores decreased significantly by an average of 6.5 ± 1.3 points at 12 months (P < 0.001). Oswestry Disability Index (ODI) scores significantly decreased at final follow-up by a mean of 62.0 ± 12.4 points (P < 0.001). Lumbar lordosis significantly improved by a mean of 3.1 ± 8.8°, while segmental lordosis significantly improved by 3.9 ± 3.1° at 12 months (P < 0.001). Anterior, middle, and posterior disc heights all experienced significant increases at 12 months by averages of 5.1 ± 3.1, 4.5 ± 2.9, and 2.4 ± 2.2 mm, respectively (P < 0.001). Neuroforaminal height significantly increased at 12 months by a mean of 3.7 ± 3.7 mm (P < 0.001). There was 99% fusion at all levels, with no findings of radiolucency and 1% pseudarthrosis observed. Only 1 (1/125, 0.8%) case of subsidence and 7 (7/125, 5.6%) cases of suspected, asymptomatic radiographic adjacent segment degeneration were reported, with no secondary revision surgeries through 12-month follow-up. ConclusionSignificant improvement of disc height, neuroforaminal height, segmental lordosis, and indirect decompression was achieved and maintained up to 1-year follow-up from baseline. Clinical outcomes were significantly improved based on appreciable decreases in VAS pain and ODI scores at final follow-up. Minimal complications were reported, with significant radiographic and patient reported outcomes observed. The use of expandable spacers, with and without adjustable lordosis, was shown to improve outcomes for the studied patient population.

Microdiscectomy for sciatica: reality check study of long-term surgical treatment effects of a Lumbosacral radicular syndrome (LSRS).

It remains unclear whether the long-term results of RCTs regarding the outcome of microdiscectomy for lumbosacral radicular syndrome (LSRS) are generalizable. The purpose of this study was to determine the external validity of the outcome preseneted in RCTs after microdicectomy for LSRS in a patient cohort from a high-volume spine center. Between 2007 and 2010, 539 patients had a single level microdiscectomy for MRI disk-related LSRS of whom 246 agreed to participate. Questionnaires includedvisual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36 and Likert scores for recovery, leg and back pain. Lumbar re-operation(s) were registered. Mean age was 51.3, and median time of follow-up was 8.0years. Re-operation occurred in 64 (26%) patients. Unfavorable perceived recovery was noted in 85 (35%) patients, and they had worse leg and back pain than the 161 (65%) patients with a favorable recovery: median VAS for leg pain 28/100mm versus 2/100mm and median VAS for back pain 9/100mm versus 3/100mm, respectively. In addition, the median RDQ and OLBD scores differed significantly: 9 vs 3 for RDQ and 26 vs 4 for OLBD, respectively (p < 0.001). In this cohort study, the long-term results after microdiscectomy for LSRSwere less favorable than those obtained in RCTs, possibly caused by less strict patient selection than in RCTs. Our findings emphasize that patients, who do not meet the same inclusion criteria for surgery as in RCTs, should be informed about the chances of a less favorable result.

Recurrent lumbar disk herniation – Fusion is the answer

Recurrent lumbar disk herniations (rLDHs) are becoming a common occurrence in present times. However, the optimal surgical strategy for their management is a not clear with discectomy alone and discectomy followed by fusion emerging as the main surgical options. In this editorial debate, we discuss why discectomy and fusion is better option for the management of such cases. The complication rates, treatment satisfaction rates, visual analog scale (VAS) leg pain scores, and rates of adjacent segment disease (ASD) requiring surgery are similar in both the groups. However, the back pain score and reoperation rates are better in fusion surgeries. Moreover, the problems needing reoperations (hardware problems and ASD) in fusion group are easier to treat. Fusion surgery is already indicated in rLDH cases with deformity, instability, and significant axial low back pain. We believe it should be considered in all cases due to negligible risk of recurrence, addressing the iatrogenic spinal instability caused due to extensive bony work, ease of surgery due to more working space, and better restoration of disk height and sagittal balance.

Usefulness of the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) for Predicting Poor Outcomes in Patients Undergoing Lumbar Decompression Surgery.

Background The Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) is an original questionnaire that evaluates psychosocial problems in orthopaedic patients. The purpose of this study was to clarify the relationship between BS-POP scores and surgical outcomes in patients with lumbar spinal stenosis (LSS). Methods From our database, a total of 157 patients with LSS who had undergone decompression surgery and completed a 1-year follow-up were retrospectively observed. The primary outcome was the numerical rating scale (NRS) score for satisfaction with surgery (from 0: not satisfied to 10: completely satisfied). Patients with an NRS score ≥8 were classified into the satisfied group. The secondary outcomes were NRS scores for low back pain, leg pain, and leg numbness and scores on the Roland–Morris Disability Questionnaire (RDQ). BS-POP was used to detect psychiatric problems before surgery. A BS-POP score ≥11 on the physician version or a combination of 10 on the physician version and ≥15 on the patient version was considered to indicate the presence of psychiatric problems. The patients were classified into two groups and compared based on preoperative BS-POP scores at the 1-year follow-up. Results Preoperatively, 22 and 135 patients showed high and low BS-POP scores, respectively. No significant differences in preoperative symptoms were found between the two groups. At 1 year after surgery, patients with high BS-POP scores showed significantly lower satisfaction with surgery, higher NRS scores for low back pain, leg pain, and leg numbness, and lower RDQ deviation scores than did the low BS-POP group (p < 0.05). The results of the multivariable analysis indicated that preoperative high BS-POP scores were independently associated with low satisfaction with surgery (odds ratio: 5.2, 95% confidence interval: 1.9–15.1). Conclusion High preoperative BS-POP scores were associated with poor outcomes for decompression surgery in patients with LSS at 1 year after surgery. These results suggest that BS-POP is a useful tool for predicting surgical outcomes in patients with LSS.

Minimally-invasive percutaneous treatments for low back pain and leg pain: a randomized controlled study of thermal disc decompression versus mechanical percutaneous disc decompression

BACKGROUND CONTEXTMinimally invasive techniques have recently been developed as alternative treatments to surgical interventions, especially for small or contained herniated disc. PURPOSEAim of our study is to assess the efficacy of the mechanical percutaneous disc decompression (PDD) in comparison with the percutaneous radiofrequency targeted disc decompression (TDD). STUDY DESIGNWe conducted a single-center noninferiority trial in which patients who had low back pain with radicular leg pain (RLP) from a contained herniated disc were randomly assigned in a 1:1 ratio to undergo either PDD or TDD. PATIENT SAMPLEFrom January 2016 to January 2017 a total of 327 patients were assessed for eligibility of whom 200 underwent randomization in the trial; 100 patients underwent the PDD and 100 underwent the TDD. OUTCOME MEASURESThe primary outcome measure was the proportion of patients who reported >50% reduction in Numeric Rating Scale (NRS) leg pain score. Secondary outcome measure included the proportion of patients who reported >30% improvement in Oswestry Disability Index (ODI) score. METHODSOutcomes of this trial were measured with the use of patient-reported data obtained from validated questionnaires to assess the low back pain with RLP before intervention and at 6 and 12 months after interventions. MRI was performed before intervention and at 6 and 12 months after interventions. In addition to NRS and ODI scores, we collected the following data: age, gender, length of hospitalizations and return to work rate. RESULTSWhen using an intention to treat analysis with those lost to follow-up and requiring a second procedure counting as failures, there were no statistically significant difference between the two treatment groups in the primary and secondary outcomes at 6 months: >50% reduction in NRS leg pain (PDD vs. TDD)=67% versus 65%; >30% ODI improvement (PDD vs. TDD)=57% versus 55%. Similarly, there were no statistically significant differences between groups in outcomes at 12 months: >50% reduction in NRS leg pain (PDD vs. TDD)=51% (95% CI 41%–60%) versus 40% (95% CI: 30%–49%); >30% ODI improvement (PDD vs. TDD)=42% (95% CI 32%–51%) versus 30% (95% CI: 21%–39%). A nonintention to treat analysis which discounted those lost to follow-up showed the only statistically significant finding was the percentage of those reporting >30% ODI at the 12 month follow-up time, favoring the PDD group: (PDD vs. TDD)=58% (95% CI 46%–69%) versus 42% (95% CI: 22%–43%). CONCLUSIONSPDD and TDD are comparable treatments for patients presenting with low back pain with RLP unresponsive to medical therapy caused by contained disc herniations.

Laterally Placed Expandable Interbody Spacers With and Without Adjustable Lordosis Improve Radiographic and Clinical Outcomes: A Two-Year Follow-Up Study.

IntroductionInterbody spacers are necessary for achieving disc height restoration when surgical intervention is used for the treatment of severe degenerative disc disease. Minimally invasive lateral lumbar interbody fusion (MIS LLIF) is a popular surgical approach that historically uses large static interbody spacers through a lateral approach. However, static spacers have been associated with iatrogenic distraction and excessive impaction forces, which may increase the risk of subsidence and loss of lordosis, compromising stability. Expandable interbody spacers with or without adjustable lordosis may help address these concerns by maximizing segmental lordosis and aiding in sagittal balance correction. This study describes the clinical and radiographic outcomes of patients treated with expandable interbody spacers with or without adjustable lordosis, for MIS LLIF.Materials and methodsThis is retrospective, single-surgeon Institutional Review Board-exempt chart review was of 103 consecutive patients who had undergone MIS LLIF at one to two contiguous level(s) utilizing expandable interbody spacers with or without adjustable lordosis (66/103 patients had adjustable lordosis spacers). Collection of clinical and radiographic functional outcomes occurred at preoperative and postoperative time points through 24 months.ResultsOne-hundred and three consecutive patients were evaluated-average age, 58.2 ± 12.1 years; 42.1% (45/107) were female. There were 78.6% (81/103) one-level cases and 21.4% (22/103) two-level cases for a total of 125 levels; 44.8% (56/125) were performed at L4-5 and 34.4% (43/125) at L3-4. The average estimated blood loss was 24.6 ± 12.3cc. Mean operative time was 61.0 ± 19.1 min, and mean fluoroscopic time was 28.2 ± 14.6 sec. Visual Analog Scale (VAS) back and leg pain scores decreased significantly by an average of 7.1 ± 1.0 points at 24 months (p<0.001). Oswestry Disability Index (ODI) scores significantly decreased by a mean of 67.4 ± 8.9 points at 24 months (p<0.001). Lumbar lordosis significantly improved by a mean of 3.1 ± 8.8° at 24 months (p=0.001). Anterior, middle, and posterior disc height significantly increased at 24 months by averages of 4.7 ± 3.1, 4.0 ± 3.0, and 2.1 ± 2.2mm, respectively (p<0.001). Neuroforaminal height had significantly increased at 24 months by a mean of 3.0 ± 3.6mm (p<0.001). Segmental lordosis significantly improved by 3.7 ± 2.9° at 24 months (p<0.001). There were 51 patients with abnormal preoperative Pelvic Incidence-Lumbar Lordosis (PI-LL) measurements that significantly improved by 9.1 ± 4.9° (p<0.001) and 52 patients with normal preoperative PI-LL measurements that improved by 0.2 ± 4.6° (p=0.748) at 24 months. One-hundred percent fusion occurred at all levels, and no findings of radiolucency were observed. One case of subsidence (1/125, 0.8%) was reported at 24 months. No implanted-related complications were reported, with 0% pseudoarthrosis and no secondary surgery required at the operative levels.ConclusionIndirect decompression and sagittal correction were achieved and maintained through a 24-month follow-up. Functional clinical outcomes significantly improved based on decreased VAS pain and ODI scores at 24 months. This study resulted in positive clinical and radiographic outcomes for patients who underwent MIS LLIF with expandable interbody spacers with or without adjustable lordosis.

Treatment for Chronic Sciatica: Do We Have New Evidence Showing That Discectomy Has Any Long-Term Benefits Over Conservative Care?

Treatment for Chronic Sciatica: Do We Have New Evidence Showing That Discectomy Has Any Long-Term Benefits Over Conservative Care?

Orthopedic disease burden in adult patients with symptomatic lumbar scoliosis: results from a prospective multicenter study.

Although the health impact of adult symptomatic lumbar scoliosis (ASLS) is substantial, these patients often have other orthopedic problems that have not been previously quantified. The objective of this study was to assess disease burden of other orthopedic conditions in patients with ASLS based on a retrospective review of a prospective multicenter cohort. The ASLS-1 study is an NIH-sponsored prospective multicenter study designed to assess operative versus nonoperative treatment for ASLS. Patients were 40-80 years old with ASLS, defined as a lumbar coronal Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20, or Scoliosis Research Society-22 questionnaire score ≤ 4.0 in pain, function, and/or self-image domains. Nonthoracolumbar orthopedic events, defined as fractures and other orthopedic conditions receiving surgical treatment, were assessed from enrollment to the 4-year follow-up. Two hundred eighty-six patients (mean age 60.3 years, 90% women) were enrolled, with 173 operative and 113 nonoperative patients, and 81% with 4-year follow-up data. At a mean (± SD) follow-up of 3.8 ± 0.9 years, 104 nonthoracolumbar orthopedic events were reported, affecting 69 patients (24.1%). The most common events were arthroplasty (n = 38), fracture (n = 25), joint ligament/cartilage repair (n = 13), and cervical decompression/fusion (n = 7). Based on the final adjusted model, patients with a nonthoracolumbar orthopedic event were older (HR 1.44 per decade, 95% CI 1.07-1.94), more likely to have a history of tobacco use (HR 1.63, 95% CI 1.00-2.66), and had worse baseline leg pain scores (HR 1.10, 95% CI 1.01-1.19). Patients with ASLS have high orthopedic disease burden, with almost 25% having a fracture or nonthoracolumbar orthopedic condition requiring surgical treatment during the mean 3.8 years following enrollment. Comparisons with previous studies suggest that the rate of total knee arthroplasty was considerably greater and the rates of total hip arthroplasty were at least as high in the ASLS-1 cohort compared with the similarly aged general US population. These conditions may further impact health-related quality of life and outcomes assessments of both nonoperative and operative treatment approaches in patients with ASLS.

Mid-term changes in spinopelvic sagittal alignment in lumbar spinal stenosis with coexisting degenerative spondylolisthesis or scoliosis after minimally invasive lumbar decompression surgery: minimum five-year follow-up

BACKGROUND CONTEXTRecently, the number of patients with lumbar spinal stenosis (LSS) who present with a coexisting spinal deformity such as degenerative spondylolisthesis (DS) and scoliosis (DLS) has been increasing. Lumbar decompression without fusion can lead to a reactive improvement in the lumbar and sagittal spinopelvic alignment, even if a sagittal imbalance exists preoperatively. However, the mid- to long-term impact of the coexistence of DS and DLS on the change in sagittal spinopelvic alignment and clinical outcomes after decompression surgery remains unknown. PURPOSEThis study aimed to investigate whether the coexistence of DS or DLS in patients with LSS is associated with differences in radiological and clinical outcomes after minimally invasive lumbar decompression surgery. STUDY DESIGN/SETTINGA retrospective analysis of prospectively collected data. PATIENT SAMPLEA total of 169 patients who underwent minimally invasive lumbar decompression surgery and follow-up >5 years postoperatively. OUTCOME MEASURESSelf-report measures: Low back pain (LBP) and/or leg pain and/or leg numbness visual analog scale (VAS) scores and the Japanese Orthopedic Association scores. PHYSIOLOGIC MEASURESStanding sagittal spinopelvic alignment. METHODSIn total, 81 patients with LSS, 50 patients with LSS and DS (≥3 mm anterior slippage), and 38 patients with LSS and DLS (≥15° coronal Cobb angle) were included in the current study. Clinical and radiological outcome results before surgery and at 2 and 5 years after surgery were compared among the groups. RESULTSIn patients with LSS with coexisting DS, the clinical outcomes at 2, and 5 years after surgery were similar to those of patients with only LSS. In patients with LSS with coexisting DLS, the VAS LBP and leg pain at 2 years after surgery was significantly higher (34.7 vs. 27.8, p=0.014; 27.8 vs. 14.7, p=0.028) and the achievement rate of the minimal clinically important difference in VAS LBP and leg pain was significantly lower than that of the LSS group (36.1% vs. 54.2%, p=0.036; 58.3% vs. 69.9%, p=0.10). The clinical outcomes except VAS leg numbness at 5 years after surgery were similar to those of patients with only LSS. The reoperation rate of the DS group was significantly lower than that of the LSS group (4.0% vs. 14.8%; p=0.01); however, the reoperation rate of the DLS group was comparable to that of the LSS group (15.8% vs. 14.8%; p=0.493). Lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence-LL had significantly improved and been maintained for 5 years after the surgery in both the DS and the DLS groups. The sagittal vertical axis had improved at two-year follow-up; however, no significant difference was observed at the 5-year follow-up in both the DS, and the DLS groups. CONCLUSIONSMid-term clinical outcomes in patients with LSS with and without deformity were comparable. Lumbar decompression without fusion can result in a reactive improvement in the lumbar and sagittal spinopelvic alignment, even with coexisting DS or DLS. Minimally invasive surgery could be considered for most patients with LSS.

Clinical results of combined interlaminar and transforaminal endoscopic discectomy for central large disc herniation

ObjectiveThe purpose of this study was to inscribe the combined interlaminar with transforaminal endoscopic discectomy for central large disc herniation and report clinical results. MethodsPatients diagnosed with large central lumbar herniated nucleus pulposus who underwent combined interlaminar and transforaminal endoscopic discectomy between 2015 and 2020 were reviewed. Perioperative data, preoperative and postoperative Oswestry Disability Index (ODI) scores, visual analog scale (VAS) back pain scores, VAS leg pain scores, and complications were evaluated and recorded at 1 week and 3 and 6 months postoperatively and each year thereafter. ResultsThe study revealed 9 cases (22.22% female). The average age of patients was 42.33 ± 19.8 years old (range, 18–83 years old). The levels of surgery were L3-4 in 22.22%, L4-5 in 77.77%. This combined approach has an average operative time of 104.44 ± 22.42 min. The VAS Back and Leg were improved from pre-operative score from 5.0 ± 2.0, 4.42 ± 2.93 to 2.18 ± 1.97 and 2.55 ± 2.84 retrospectively at 1 week. The ODI score was improved pre-operative from 46.85 ± 15.61% to 14.94 ± 19.08% at 3 month follow up. There were 2 cases (22.22%) diagnosed of recurrent disc herniation. No case of epidural hematoma, infection, permanent neurological deterioration, cauda equina syndrome. ConclusionsCombined interlaminar and transforminal endoscopic discectomy is an option for central large lumbar disc herniation.

Lateral lumbar interbody fusion using a cellular allogeneic bone matrix in the treatment of symptomatic degenerative lumbar disc disease and lumbar spinal instability.

Cellular allogeneic bone grafts are used as a biologic adjuvant in lumbar spinal fusions. The clinical use of a minimally invasive extreme lateral approach to the lumbar spine has been widely adopted; however, there are few clinical studies that have documented the clinical and radiographic outcomes associated with the use of cellular allografts as an adjunct to fusion in this advanced surgical approach. A consecutive series of 67 patients (34 males and 33 females) with a mean age of 66.8 years (26-85 years) who underwent single- or multilevel lateral lumbar interbody fusion (LLIF) with supplemental posterior segmental spinal fixation using a cellular allogeneic bone matrix as the only bone graft material was retrospectively reviewed by a single surgeon. Patients' preoperative and 3- and 12-month postoperative data were studied. All patients were followed for a minimum of 12 months. Standardized clinical outcome measures-36-Item Short Form Surgery (SF-36), Oswestry Disability Index (ODI), and visual analog scale (VAS) back and leg pain scores-were used to evaluate the clinical outcomes. An average of 2.25 levels was treated per patient (151 total levels). Fusion status was assessed by dynamic radiographs and computed tomography (CT) scans. The statistical method used to identify the significance of the observed changes in clinical outcomes was the paired 2-sided t-tests. Significance was ascribed to P values <0.05. Fusion was achieved at 142 levels (142/151; 94%). Eight levels (8/151; 5.3%) showed partial fusions and one patient (single level) had no fusion. In the group of patients with fusions, the mean back and leg pain scores showed improvement from preoperative scores at both 3 and 12 months (P<0.001). Functional outcomes showed similar clinical success in both in SF-36 and ODI scores. The use of a cellular allogeneic bone matrix provided osteoconductive and osteoinductive components for successful spine fusions and was associated with statistically significant improvement in SF-36, VAS, and ODI scores.

EPIDURAL STEROID INJECTION IN HERNIATED DISC AND LUMBAR CANAL STENOSIS: IS IT JUST A PLACEBO?

ABSTRACT Objective To study the role of epidural steroid injection (ESI) in patients with lumbar disc herniation (LDH) and lumbar canal stenosis (LCS). ESIs are regularly used to support non-operative treatment for LBP, and our anecdotal impression is that a considerable proportion of patients report substantial pain relief after ESI. Methods One thousand consecutive patients (645 patients with LDH and 355 patients with LCS) who required ESI from January-August 2018 were included. All were given the same ESI, prepared with triamcinolone (80 mg), bupivacaine (0.25%, 4 ml) and normal saline (4 ml). Patients were evaluated using the numerical rating scale (NRS) immediately after the injection, after 7 days, and after 3 months. Results The mean NRS back-pain score of the LDH-group was reduced from 5 (range: 4-8) to 4 (range: 2-7) immediately after injection, 2 (range: 1-7) after 7 days and 2 (range: 1-7) after 3 months (p-value&lt;0.001). The mean NRS back-pain score of the LCS-group was reduced from 5 (range: 4-8) to 4 (range: 2-7) immediately after injection, 2 (range: 1-7) after 7 days and 3 (range: 1-7) after 3 months (p-value &lt;0.001). The mean NRS leg-pain score of the LDH group was reduced from 5 (range: 4-9) to 3 (range: 3-7) immediately after injection, 1 (range: 1-6) after 7 days and 2 (range: 1-7) after 3 months (p-value &lt;0.001). The mean NRS leg-pain score of the LCS group was reduced from 5 (range: 4-9) to 4 (range: 3-7) immediately after injection, 3 (range: 1-7) after 7 days and 2 (range 1-6) after 3 months (p-value &lt;0.001). Conclusion ESI causes statistically significant improvement in back and leg pain in patients with LDH and LCS. However, the short and medium-term efficacy of ESI in the LCS group was lower than in the LDH group. Level of evidence IV; Prospective hospital-based study.