Lumbar Decompression Surgery Research Articles

A cost-utility analysis between decompression only and fusion surgery for elderly patients with lumbar spinal stenosis and sagittal imbalance

Lumbar spinal stenosis (LSS) and sagittal imbalance are relatively common in elderly patients. Although the goals of surgery include both functional and radiological improvements, the criteria of correction may be too strict for elderly patients. If the main symptom of patients is not forward-stooping but neurogenic claudication or pain, lumbar decompression without adding fusion procedure may be a surgical option. We performed cost-utility analysis between lumbar decompression and lumbar fusion surgery for those patients. Elderly patients (age > 60 years) who underwent 1–2 levels lumbar fusion surgery (F-group, n = 31) or decompression surgery (D-group, n = 40) for LSS with sagittal imbalance (C7 sagittal vertical axis, C7-SVA > 40 mm) with follow-up ≥ 2 years were included. Clinical outcomes (Euro-Quality of Life-5 Dimensions, EQ-5D; Oswestry Disability Index, ODI; numerical rating score of pain on the back and leg, NRS-B and NRS-L) and radiological parameters (C7-SVA; lumbar lordosis, LL; the difference between pelvic incidence and lumbar lordosis, PI-LL; pelvic tilt, PT) were assessed. The quality-adjusted life year (QALY) and incremental cost-effective ratio (ICER) were calculated from a utility score of EQ-5D. Postoperatively, both groups attained clinical and radiological improvement in all parameters, but NRS-L was more improved in the F-group (p = 0.048). ICER of F-group over D-group was 49,833 US dollars/QALY. Cost-effective lumbar decompression may be a recommendable surgical option for certain elderly patients, despite less improvement of leg pain than with fusion surgery.

Time of Discharge and 30-Day Re-Presentation to an Acute Care Setting After Elective Lumbar Decompression Surgery.

Evidence regarding the consequence of efforts to increase patient throughput and decrease length of stay in the context of elective spine surgery is limited. To evaluate whether early time of discharge results in increased rates of hospital readmission or return to emergency department for patients admitted after elective, posterior, lumbar decompression surgery. We conducted a retrospective cohort study of 779 patients admitted to hospital after undergoing elective, posterior, lumbar decompression surgery. Multiple logistic regression evaluated the relationship between time of discharge and the primary outcome of return to acute care within 30 days, while controlling for sociodemographic, procedural, and discharge characteristics. In multiple logistic regression, time of discharge earlier in the day was not associated with increased odds of return to acute care within 30 days (odds ratio [OR] 1.18, 95% CI 0.92-1.52, P = .19). Weekend discharge (OR 1.99, 95% CI 1.04-3.79, P = .04) increased the likelihood of return to acute care. Surgeon experience (<1 year of attending practice, OR 0.43, 95% CI 0.19-1.00, P = .05 and 2-5 years of attending practice, OR 0.50, 95% CI 0.25-1.01, P = .054), weekend discharge (OR 0.49, 95% CI 0.27-0.89, P = .02), and physical therapy evaluation (OR 0.20, 95% CI 0.12-0.33, P < .001) decreased the likelihood of discharge before noon. Time of discharge is not associated with risk of readmission or presentation to the emergency department after elective lumbar decompression. Weekend discharge is independently associated with increased risk of readmission and decreased likelihood of prenoon discharge.

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

PurposeSymptomatic lumbar spinal stenosis can be treated with decompression surgery. A recent review reported that, after decompression surgery, 1.6–32.0% of patients develop postoperative symptomatic spondylolisthesis and may therefore be indicated for lumbar fusion surgery. The latter can be more challenging due to the altered anatomy and scar tissue. It remains unclear why some patients get recurrent neurological complaints due to postoperative symptomatic spondylolisthesis, though some associations have been suggested. This study explores the association between key demographic, biological and radiological factors and postoperative symptomatic spondylolisthesis after lumbar decompression.MethodsThis retrospective cohort study included patients who had undergone lumbar spinal decompression surgery between January 2014 and December 2016 at one of two Spine Centres in the Netherlands or Switzerland and had a follow-up of two years. Patient characteristics, details of the surgical procedure and recurrent neurological complaints were retrieved from patient files. Preoperative MRI scans and conventional radiograms (CRs) of the lumbar spine were evaluated for multiple morphological characteristics. Postoperative spondylolisthesis was evaluated on postoperative MRI scans. For variables assessed on a whole patient basis, patients with and without postoperative symptomatic spondylolisthesis were compared. For variables assessed on the basis of the operated segment(s), surgical levels that did or did not develop postoperative spondylolisthesis were compared. Univariable and multivariable logistic regression analyses were used to identify associations with postoperative symptomatic spondylolisthesis.ResultsSeven hundred and sixteen patients with 1094 surgical levels were included in the analyses. (In total, 300 patients had undergone multilevel surgery.) ICCs for intraobserver and interobserver reliability of CR and MRI variables ranged between 0.81 and 0.99 and 0.67 and 0.97, respectively. In total, 66 of 716 included patients suffered from postoperative symptomatic spondylolisthesis (9.2%). Multivariable regression analyses of patient-basis variables showed that being female [odds ratio (OR) 1.2, 95%CI 1.07–3.09] was associated with postoperative symptomatic spondylolisthesis. Higher BMI (OR 0.93, 95%CI 0.88–0.99) was associated with a lower probability of having postoperative symptomatic spondylolisthesis.Multivariable regression analyses of surgical level-basis variables showed that levels with preoperative spondylolisthesis (OR 17.30, 95%CI 10.27–29.07) and the level of surgery, most importantly level L4L5 compared with levels L1L3 (OR 2.80, 95%CI 0.78–10.08), were associated with postoperative symptomatic spondylolisthesis; greater facet joint angles (i.e. less sagittal-oriented facets) were associated with a lower probability of postoperative symptomatic spondylolisthesis (OR 0.97, 95%CI 0.95–0.99).ConclusionBeing female was associated with a higher probability of having postoperative symptomatic spondylolisthesis, while having a higher BMI was associated with a lower probability. When looking at factors related to postoperative symptomatic spondylolisthesis at the surgical level, preoperative spondylolisthesis, more sagittal orientated facet angles and surgical level (most significantly level L4L5 compared to levels L1L3) showed significant associations. These associations could be used as a basis for devising patient selection criteria, stratifying patients or performing subgroup analyses in future studies regarding decompression surgery with or without fusion.

The Effect of Cervical and Lumbar Decompression Surgery for Spinal Stenosis on Erectile Dysfunction.

Observational study. To evaluate the prevalence of erectile dysfunction and evaluate the effects of decompressive surgery on erectile dysfunction in cervical spinal stenosis and lumbar canal stenosis patients. This observational, prospective analysis enrolled patients aged 18-80 with cervical spinal stenosis and/or lumbar canal stenosis that underwent respective decompressive surgery. The IIEF-5 questionnaire was administered preoperatively, and at 6- and 12-months postoperatively to assess erectile dysfunction severity. The EPIC database was queried to determine any postoperative complications and document prominent erectile dysfunction risk factors. Of 79 patients included in the analysis, 42 (53.2%) completed the IIEF-5 at 6months, and 62 (78.5%) completed it at 12months. Eighteen had cervical stenosis only, 54 had lumbar stenosis only, and 7 had both. 72% (18/25) of cervical stenosis patients and 83.6% (51/61) of lumbar stenosis patients had erectile dysfunction preoperatively according to IIEF-5 responses. The average preoperative IIEF-5 score indicated significant presence of erectile dysfunction for both the cervical and lumbar stenosis groups. No significant differences were identified in IIEF-5 score deltas from pre- to both postoperative periods. The presence of erectile dysfunction in both the cervical and lumbar stenosis groups was not significantly associated with the presence of any documented risk factors. Our results suggest no significant improvement in overall erectile function postoperatively for patients with preoperative erectile dysfunction. This is important to address during patient counseling for decompression surgery candidates with cervical spinal stenosis and/or lumbar canal stenosis to manage expectations.

Predictive factors for residual leg numbness after decompression surgery for lumbar degenerative diseases

BackgroundThe purpose of this study is to evaluate the change patterns of leg numbness (LN) after lumbar decompression surgery (LDS), and to find the predictive factors that affect the recovery of numbness.MethodsPatients who underwent LDS in our institution between August 2020 and July 2021 were prospectively enrolled in this study, and were followed by a 12-month follow-up. The degree of LN, leg pain (LP) and the disability were assessed using the visual analog scale (VAS) and oswestry disability index (ODI).ResultsA total of 314 patients finished the 12-month follow-up. The preoperative mean VAS-LN score was 3.49 ± 2.44, which decreased to 1.91 ± 1.30 at 3 months, to 1.29 ± 0.97 at 6 months and to 1.26 ± 0.96 at 12 months after surgery. The preoperative mean VAS-LP score was 6.05 ± 1.30, which decreased to 2.00 ± 0.86 at 3 months, to 1.02 ± 0.80 at 6 months, and to 0.49 ± 0.71 at 12 months after surgery. The preoperative mean ODI score was 27.90 ± 7.08, which decreased to 9.73 ± 3.09 at 3 months, to 6.72 ± 2.98 at 6 months, and to 4.57 ± 2.76 at 12 months after surgery. Via multivariate logistic regression analysis, only preoperative VAS-LN score (p < 0.001*) was identified as a significantly independent predictive factor for residual LN after operation.ConclusionClinically significant improvement in LN was observed in the majority of patients within 6 months after LDS, and the improvement of VAS-LN was slower than the VAS-LP. High pre-operative VAS-LN score can independently predict the presence of residual LN after surgery at 12-month follow up.

Patient-level payment patterns prior to single level lumbar decompression are associated with resource utilization, postoperative payments, and adverse events

Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions. 1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events. Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015). Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394). Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression. We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile. There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events. III.

The Ideal Threshold of Hemoglobin A1C in Diabetic Patients Undergoing Elective Lumbar Decompression Surgery.

Retrospective cohort study. To evaluate the association of Hemoglobin A1C (HbA1c) with surgical site infection (SSI) and patient-reported outcomes (PROs), and to identify optimal HbA1c thresholds to minimize the risk of SSI and maximize PROs. Diabetes mellitus has been associated with worsened outcomes following spine surgery. HbA1c, a surrogate of glycemic control, is an important assessment tool in diabetic patients. A single-center, retrospective cohort study using prospectively collected data was undertaken. Diabetic patients undergoing elective lumbar decompression surgery between October 2010 and May 2021 were included. HbA1c, demographics, comorbidities, and perioperative data were collected. Primary outcomes included: 1) SSI, and 2) PROs, including the Numeric Rating Scale (NRS)-back/leg pain and Oswestry Disability Index (ODI). Secondary outcomes included: complications, readmissions, and reoperations within 90-days postoperatively. The minimum clinically important difference (MCID) was set at a 30% improvement from baseline PROs. Of 1819 patients who underwent lumbar decompression surgery, 368 patients had diabetes mellitus, and 177 had a documented preoperative HbA1c value. Of patients with available HbA1c values, the mean age was 62.5±12.3, the mean HbA1c value was 7.2±1.5%, and SSI occurred in 3 (1.7%) patients only, which prevented further analysis of SSI and HbA1c. A significant association was seen with a higher HbA1c and failure to achieve NRS-Back pain MCID30 [Odds ratio(OR)=0.53, 95% confidence interval(CI) 0.42-0.78; P =0.001] and ODI MCID30 (OR=0.58, 95%CI 0.44-0.77; P =0.001), but not NRS-Leg pain MCID30 (OR=1.29, 95%CI 0.86-1.93; P =0.208). ROC-curve analysis and Youden's index revealed an HbA1c threshold of 7.8 for NRS-Back pain MCID30 (AUC=0.65, P <0.001) and 7.5 for ODI MCID30 (AUC=0.65, P =0.001). In diabetic patients undergoing elective lumbar decompression surgery, HbA1c levels above 7.8 and 7.5 were associated with less improvement of NRS-Back and ODI scores at 12-months postoperatively, respectively. To optimize PROs, We recommend a preoperative HbA1c of 7.5 or below for diabetic patients undergoing elective lumbar decompression surgery.

Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes.

Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery. The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval. A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery. Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.

Implementation of Machine Learning to Predict Cost of Care Associated with Ambulatory Single-Level Lumbar Decompression

With the emergence of the concept of value-based care, efficient resource allocation has become an increasingly prominent factor in surgical decision-making. Validated machine learning (ML) models for cost prediction in outpatient spine surgery are limited. As such, we developed and internally validated a supervised ML algorithm to reliably identify cost drivers associated with ambulatory single-level lumbar decompression surgery. A retrospective review of the New York State Ambulatory Surgical Database was performed to identify patients who underwent single-level lumbar decompression from 2014 to 2015. Patients with a length of stay of >0 were excluded. Using pre- and intraoperative parameters (features) derived from the New York State Ambulatory Surgical Database, an optimal supervised ML model was ultimately developed and internally validated after 5 candidate models were rigorously tested, trained, and compared for predictive performance related to total charges. The best performing model was then evaluated by testing its performance on identifying relationships between features of interest and cost prediction. Finally, the best performing algorithm was entered into an open-access web application. A total of 8402 patients were included. The gradient-boosted ensemble model demonstrated the best performance assessed via internal validation. Major cost drivers included anesthesia type, operating room time, race, patient income and insurance status, community type, worker's compensation status, and comorbidity index. The gradient-boosted ensemble model predicted total charges and associated cost drivers associated with ambulatory single-level lumbar decompression using a large, statewide database with excellent performance. External validation of this algorithm in future studies may guide practical application of this clinical tool.

The Effect of Exercise Interventions After Lumbar Decompression Surgery: A Systematic Review and Meta-Analysis

The purpose of the present systematic review was to evaluate the effectiveness of exercise after lumbar decompression surgery on pain, function, motor-sensory symptoms, and psychosocial parameters. A literature search was conducted with PubMed, Web of Science, Scopus, ScienceDirect, and Cochrane databases. Quality analysis and bias risk assessment were performed with "Physiotherapy Evidence Database" and "Revised Cochrane risk-of-bias tool randomized trials", respectively. A total of 1219 articles were accessed from the relevant databases (PubMed = 97, Cochrane = 61, Web of Science = 97, Scopus = 104, ScienceDirect = 860). Fourteen studies were included in the systematic review. Systematic review results were presented with narrative synthesis due to heterogeneous data. Homogeneous data were given with meta-analysis. The results demonstrated that strengthening, stabilization, and aerobic exercises provide additional advantages after lumbar decompression than education or clinical advice alone. Studies also emphasized the importance of relaxation, stretching, and mobilization training. The exercise training provided an additional advantage in terms of disability score at 6-12 weeks (short- to moderate-term) follow-up (effect size [ES]: -0.87, 95% confidence interval [CI]: -1.30; -0.45) with high-degree evidence. However, results in the identical pooling for pain scores showed low efficacy (ES: -0.35, 95% CI: -0.76; 0.05). Short Form-36 pooling in the 12-week follow-up demonstrated that exercise training had moderate-degree evidence effectiveness on physical function (ES: 0.51, 95% CI: 0.12; 0.91), bodily pain (ES: 0.52, 95% CI: 0.13; 0.91), and social function (ES: 0.53, 95% CI: 0.13; 0.93). The results highlighted the importance of exercise training, particularly strengthening. Meta-analysis results also proved the effectiveness of exercise on disability in the short to medium term.

152. The association of opioid use disorder on perioperative outcomes following lumbar spine laminectomy

<h3>BACKGROUND CONTEXT</h3> Opioid use disorder (OUD) is characterized by a pattern of excessive, chronic opioid use leading to problems or distress, which can involve misuse of prescription medication, use of diverted medication or illegally obtained heroin. Studies have reported the prevalence of patients who consume opioids prior to spine surgery to be as high as 72%. Additionally, chronic opioid use and misuse have been linked to several complications following spine surgery. <h3>PURPOSE</h3> The purpose of this study was to determine the association of OUD on perioperative. outcomes following lumbar spine laminectomy. Specifically, we investigated the impact of OUD on: 1) in-hospital LOS, 2) readmission rates, 3) medical complications and 4) health care expenditures. <h3>STUDY DESIGN/SETTING</h3> A retrospective analysis from January 1st, 2005 to March 31st, 2014, of the 100% Medicare Standard Analytical Files (SAF) was performed from the for-fee based PearlDiver (PearlDiver Technologies, Fort Wayne, Indiana, United States) database. <h3>PATIENT SAMPLE</h3> The dataset was initially queried for all patients who underwent lumbar spine laminectomy using the following CPT codes: 63005, 63012, 63017 and 63047. Patients who had OUD were identified using ICD-9 diagnostic codes 304.01, 304.02, 305.51 and 305.52. These procedural and diagnostic codes were utilized as they have been used in previously published studies. A total of 131,635 patients who underwent lumbar spine laminectomy were identified for analysis following the inclusion/exclusion criteria. Of these cases, 3,515 (2.67%) had OUD while 128,120 (97.3%) served as the comparison cohort. <h3>OUTCOME MEASURES</h3> Primary endpoints of the study were to compare in-hospital LOS, readmission rates, medical complications, and healthcare expenditures. Readmission rates and medical complications were those which occurred within the 90-day episode of care interval. Complications analyzed included: acute kidney injuries, cerebrovascular accidents, deep vein thromboses, ileus episodes, myocardial infarctions, pneumoniae, pulmonary emboli, respiratory failures, transfusion of blood products, urinary tract infections, and venous thromboemboli. For health care expenditures, day of surgery and total global 90-day episode of care interval costs were analyzed using reimbursement data. Reimbursements were chosen as they are a more accurate predictor of what providers are paid from the insurance companies. <h3>METHODS</h3> Baseline demographics of the two cohorts were analyzed using Pearson's Chi-Square Analyses or Fischer's Exact test for categorical variables. For continuous variables, Welch's t-tests were used to assess for significance for LOS, healthcare expenditures, and mean Elixhauser Comorbidity Index scores between the two cohorts. A multivariate binomial logistic regression model was constructed to determine the association of OUD on readmission rates and medical complications. The model was adjusted for age, sex, alcohol use disorder, chronic obstructive pulmonary disease (COPD), diabetes mellitus, general anxiety disorder, hyperlipidemia, hypertension, obesity - defined as a body mass index (BMI) greater than 30 kilograms per meter squared (kg/m²) and tobacco use. These comorbid conditions were entered into the regression model as studies have shown OUD to be associated with these comorbid conditions. Incidency and Odds Ratios (OR) are reported. To reduce the probability of a type I error, a Bonferroni-correction was performed, and a p-value less than 0.001 was considered to be statistically significant. <h3>RESULTS</h3> Patients with an OUD undergoing lumbar laminectomy had significantly longer in-hospital LOS (3.68 days vs. 1.13 days, p<0.0001). Readmission rates were significantly higher (14.57% vs 7.39%, OR: 1.73, p < 0.0001) of 90-day medical complications including transfusion of blood products (0.54% vs 0.15%, OR: 5.12, 95% CI: 2.92 -8.48, p < 0.0001), in patients who had an OUD. The study cohort was found to have higher incidence and odds (32.36% vs 9.76%, OR: 3.53, p<0.0001), pneumoniae (6.29% vs 1.23%, OR: 5.23, 95% CI: 3.57 - 4.99, p<0.0001), respiratory failures (0.54% vs 0.12%, OR: 4.07, 95% CI: 2.29 - 6.87, p<0.0001), urinary tract infections (14.54% vs 4.49%, OR: 3.57, 95% CI: 3.19 - 3.97, p<0.0001), acute kidney injuries (4.84% vs 1.36%, OR: 3.31, 95% CI: 2.75 - 3.95, p<0.0001), in addition to other medical complications compared to patients without OUD. Patients with OUD had higher total global 90-day episode of care reimbursement rates ($13,635.81 vs $8,131.20, p<0.0001) compared to their counterparts. <h3>CONCLUSIONS</h3> Patients with an OUD are at a significant risk for increased in-hospital LOS, readmission rates, medical complications and health care expenditures following lumbar decompression surgery. Spine surgeons should seek to identify patients with an OUD and determine strategies to optimize patient care in the perioperative course of lumbar surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

111. Risk factors for ambulatory surgery conversion to extended stay among patients undergoing one- or two-level posterior lumbar decompression

<h3>BACKGROUND CONTEXT</h3> Ambulatory surgery (AMS), or outpatient surgery, is increasingly common for patients with lumbar spine disease. Previous reports suggest AMS is associated with lower cost and similar quality of care compared to conventional inpatient spine surgery. Under the current Center for Medicare and Medicaid services (CMS) two-midnight rule, a prolonged stay beyond 48 hours is considered an inpatient admission. AMS patients may unintentionally be subjected to extended hospital stays, which can lead to higher medical costs. An unanticipated extension of hospitalization can be a great burden not only to patients, but to medical providers and insurance companies. However, little is known about the risk factors for AMS conversion to extended stay. <h3>PURPOSE</h3> To investigate the factors associated with the conversion of patient status from ambulatory surgery (outpatient) to observation stay (OS) (less than 48 hours) or inpatient (greater than 48 hours). <h3>STUDY DESIGN/SETTING</h3> Retrospective study. <h3>PATIENT SAMPLE</h3> This study included 1,096 adult patients undergoing one- or two-level lumbar decompression surgery at a single academic institution from January 1, 2019 to March 16, 2020. <h3>OUTCOME MEASURES</h3> Conversion rate and risk factors from AMS to OS or inpatient. <h3>METHODS</h3> Ethical board approval was obtained for this study. The records of patients who underwent one- or two-level lumbar decompression surgery planned for AMS were retropectively reviewed. Patients were categorized in three groups based on length of stay that consisted of AMS, OS (less than 48-hour stay), and inpatient (staying greater than 48 hours). Data on patient demographics, medical co-morbidities, surgical information including intraoperative complications and postsurgical pain scores, and administrative information such as operation start time were collected. Simple and multivariable logistic regression analyses were conducted comparing AMS patients and OS/inpatient. Statistical signicance was defined as p <0.05. <h3>RESULTS</h3> Of the 1,096 patients, 641 (58%) patients were converted to either OS (486, 44%) or inpatinet (155, 14%) status. The multivariable analysis demonstrated that age (>80 years old), high ASA grade, history of sleep apnea, drain use, high estimated blood loss, long operation, laminectomy for spinal stenosis, late operation start time, and a high pain score in the acute care unit were considered independent risk factors for AMS conversion to OS/inpatient status. <h3>CONCLUSIONS</h3> Our results indicated that several surgical factors along with patient factors are significantly associated with AMS conversion. Addressing modifiable surgical factors, such as blood loss and operation start time and postoperative pain management might reduce the AMS conversion rate and be beneficial to patients and facilities. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Surgical management of high-grade lumbar spondylolisthesis associated with Hajdu-Cheney syndrome: illustrative case.

Hajdu-Cheney syndrome (HCS) is a rare connective tissue disorder characterized by severe bone demineralization. In the spine, it is associated with the early onset of severe osteoporosis and can cause spondylolisthesis. Spinal instrumentation in the setting of severe osteoporosis is challenging because of poor resistance of vertebrae to biomechanical stress. A 59-year-old woman with known idiopathic HCS presented with a grade 4 L5-S1 spondylolisthesis and right L5 pedicle fracture associated with a left L5 pars fracture, causing a progressive L5 radiculopathy that was worse on the left side than the right side and bilateral foot drop. The authors performed decompressive lumbar surgery, which included a complete L5 laminectomy and resection of the left L5 pedicle. This was followed by multilevel lumbosacral instrumentation using cement-augmented fenestrated pedicle screws as well as transdiscal sacral screws and bilateral alar-iliac fixation. Postoperatively, the radicular pain resolved, and the left foot drop partially recovered. Stabilization of high-grade spondylolisthesis in the setting of bone demineralization disorders is challenging. The use of different instrumentation techniques is important because it increases biomechanical stability of the overall instrumentation construct.

Hemodynamic protective effects of epinephrine containing saline irrigation in biportal endoscopic lumbar surgery.

During endoscopic orthopedic surgery, epinephrine mixed with irrigation saline is frequently used to improve visualization. By monitoring hemodynamic parameters throughout the procedure, we intended to discover the hemodynamic effect of epinephrine between the normal saline irrigation fluid without epinephrine group (NS) and normal saline irrigation fluid with epinephrine group (EPI).Patients who underwent 1-level lumbar decompression or discectomy surgery without fusion between August 2019 and July 2020 were reviewed retrospectively. The hemodynamic parameters were compared between the NS group and EPI group. As a second endpoint, the incidence of hypotension and hypertension events, expected blood loss, postoperative nausea and vomiting and postoperative epidural hematoma were compared between the 2 groups.The 2 groups were homogeneous in terms of age, sex, weight, height, body mass index (BMI), ASA physical status (ASA PS), and diagnosis. The incidence of hypotension events (67.2 % in the NS group, 45.7 % in the EPI group, P =.015) and severe hypotension events (51.7 % in the NS group, 28.6 % in the EPI group, P = .015) were less frequent in the EPI group. Only epinephrine had a significant protective effect through a multivariable analysis (P = .027, OR = 2.361) and in severe hypotension events, only epinephrine had a significant protective effect through a multivariable analysis (P = .011, OR = 2.818), and EBL was the risk factor through a multivariable analysis (P = .016, OR = 1.002)We believe that the addition of epinephrine to irrigation saline has hemodynamic protective effects in patients who underwent endoscopic lumbar surgery.

Prognostic Factors and Optimal Surgical Management for Lumbar Spinal Canal Stenosis in Patients with Diffuse Idiopathic Skeletal Hyperostosis.

Lumbar spinal canal stenosis (LSS) and diffuse idiopathic skeletal hyperostosis (DISH) tend to develop in the elderly, resulting in an increased need for lumbar surgery. However, DISH may be a risk factor for poor clinical outcomes following lumbar decompression surgery, especially in patients with DISH extending to the lumbar segment (L-DISH). This study aimed to identify the prognostic factors of LSS with L-DISH and propose an optimal surgical management approach to improve clinical outcomes. Of 934 patients who underwent lumbar decompression surgery, 145 patients (15.5%) had L-DISH. In multivariate linear regression analysis of the JOA score improvement rate, the presence of vacuum phenomenon at affected segments (estimate: −15.14) and distance between the caudal end of L-DISH and decompressed/fused segments (estimate: 7.05) were independent prognostic factors. In logistic regression analysis of the surgical procedure with JOA improvement rate > 25% in L-DISH patients with both negative prognostic factors, the odds ratios of split laminotomy and short-segment fusion were 0.64 and 0.21, respectively, with conventional laminotomy as the reference. Therefore, to achieve better clinical outcomes in cases with decompression at the caudal end of L-DISH, decompression surgery without fusion sparing the osteoligamentous structures at midline should be considered as the standard surgery.

Performance of Artificial Intelligence-Based Algorithms to Predict Prolonged Length of Stay after Lumbar Decompression Surgery.

Background: Decompression of the lumbar spine is one of the most common procedures performed in spine surgery. Hospital length of stay (LOS) is a clinically relevant metric used to assess surgical success, patient outcomes, and socioeconomic impact. This study aimed to investigate a variety of machine learning and deep learning algorithms to reliably predict whether a patient undergoing decompression of lumbar spinal stenosis will experience a prolonged LOS. Methods: Patients undergoing treatment for lumbar spinal stenosis with microsurgical and full-endoscopic decompression were selected within this retrospective monocentric cohort study. Prolonged LOS was defined as an LOS greater than or equal to the 75th percentile of the cohort (normal versus prolonged stay; binary classification task). Unsupervised learning with K-means clustering was used to find clusters in the data. Hospital stay classes were predicted with logistic regression, RandomForest classifier, stochastic gradient descent (SGD) classifier, K-nearest neighbors, Decision Tree classifier, Gaussian Naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), multilayer perceptron artificial neural network (MLP), and radial basis function neural network (RBNN) in Python. Prediction accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors. Further, we developed a decision tree based on the Chi-square automatic interaction detection (CHAID) algorithm to investigate cut-offs of predictors for clinical decision-making. Results: 236 patients and 14 feature variables were included. K-means clustering separated data into two clusters distinguishing the data into two patient risk characteristic groups. The algorithms reached AUCs between 67.5% and 87.3% for the classification of LOS classes. Feature importance analysis of deep learning algorithms indicated that operation time was the most important feature in predicting LOS. A decision tree based on CHAID could predict 84.7% of the cases. Conclusions: Machine learning and deep learning algorithms can predict whether patients will experience an increased LOS following lumbar decompression surgery. Therefore, medical resources can be more appropriately allocated to patients who are at risk of prolonged LOS.

The incidence of failed back surgery syndrome varies between clinical setting and procedure type

BackgroundFailed back surgery syndrome (FBSS) is a significant cause of lumbar disability and is associated with severe patient morbidity. As the etiology of FBSS is not completely elucidated, the risk factors and evaluation of patients with FBSS remains challenging. Our analysis of a wide variety of operation types, clinical setting, and their correlation to FBSS seeks to allow fellow clinicians to be aware of the potential risk factors that leads to this devastating diagnosis. MethodsData were obtained for patients undergoing anterior lumbar fusion, posterior lumbar fusion, or decompression procedures from January 2010 to December 2017 from the Mariner insurance database. Rates of FBSS at six- and twelve-months post-surgery were determined for patients undergoing single/multilevel procedures according to place of service, and approach/procedure type. ResultsFrom 2010 to 2017, 102,047 patients underwent lumbar fusion or decompression surgery (54% decompression procedures, 36% posterior fusions, and 8.9% anterior fusions).5.4% of patients were diagnosed with FBSS within six months of the index procedure, and 8.4% were diagnosed with FBSS within twelve months. FBSS was higher in the inpatient (6.0%) vs. outpatient (4.3%) cohort. Among the surgical techniques, multi-level procedures had significantly higher rates of FBSS than single-level procedures, the highest being 10% in multi-level inpatient decompression procedures (p < 0.05). ConclusionThe highest rates of FBSS occurred in in the elderly (age group 70–74), for those patients whose index procedure was received in an inpatient setting, as well as for those receiving a multi-level surgery.

Incidence of postoperative progressive segment degeneration at decompression and adjacent segments after minimally invasive lumbar decompression surgery: a 5-year follow-up study.

There are several reported studies on the incidence of adjacent segment disease (ASD) after lumbar fusion surgery; however, the incidence of ASD after decompression surgery has not been well studied. In this study the authors aimed to investigate the incidence of progressive segment degeneration (PSD) at the decompression and adjacent segments 5 years after minimally invasive lumbar decompression surgery. We investigated data from 168 patients (mean age, 69.5 ± 9.2 years) who underwent bilateral microscopic or microendoscopic decompression surgery via a unilateral approach and were followed up for more than 5 years. Outcomes were self-reported visual analog scale (VAS) scores for low-back pain, leg pain, and leg numbness and physician-assessed Japanese Orthopaedic Association (JOA) scores for back pain. Changes in the disc height and movement of the adjacent lumbar segments were compared using preoperative and 5-year postoperative lateral full-length standing whole-spine radiographic images. PSD was defined as loss of disc height > 3 mm and progression of anterior or posterior slippage > 3 mm. The incidence and clinical impact of PSD were investigated. The mean JOA score improved significantly in all patients from 13.4 points before surgery to 24.1 points at the latest follow-up (mean recovery rate 67.8%). PSD at the decompression site was observed in 43.5% (73/168) of the patients. The proportions of patients with loss of disc height > 3 mm and slippage progression were 16.1% (27/168) and 36.9%, respectively (62/168: 41 anterior and 21 posterior). The proportion of patients with PSD at the adjacent segment was 20.5% (35/168), with 5.4% (9/168) of the patients with loss of disc height > 3 mm and 16.0% (27/168: 13 anterior and 14 posterior) with slippage progression. There was no significant difference in the clinical outcomes between patients with and those without PSD. Radiological ASD was observed even in the case of decompression surgery alone. However, there was no correlation with symptom deterioration, measured by the VAS and JOA scores.

Incidental Dural Tears in Lumbar Decompressive Surgery: Incidence, Causes, Treatment, Results

Durotomy (Incidental dural tears or ID) is a very rarely occurring disorder when decompressive surgery (spinal surgery) of the patients takes place. This disorder has severe effects on patients. During different surgeries of the spinal cord, the chances of this durotomy vary greatly. Objective: The main objective of this research work is to evaluate the main reasons for the incidence of this durotomy disease. During different surgeries of the spinal cord surgeries (decompressive and compressive) within the different regions, many factors play their role in the initiation of this durotomy disease. It is the target of this work to find the initiation factors of the disease so that effective methods of treatment can also find out. Methods: It was a retrospective study with a statistical approach. This study was conducted in Neurosurgery unit, Mardan medical complex / Bacha khan medical college, Mardan for the Duration of one year August 2020 to July 2021. To proceed with this study, 30 patients were selected with posterolateral and posterior compressive and decompressive surgeries within the different regions of the spinal cord. The patients were randomly selected from December 2020 to December 2021. Results: The incidence of this durotomy disease was investigated within all groups and the probability of this disease was only 12.65%. The occurrence of this disease also depends upon the type of surgery. Patients suffering from spinal trauma, stenosis of the spinal, different tumors, and vertebral disc herniation had exaggerating role in the incidence of durotomy in patients having some spinal surgery. Conclusion: The durotomy disease should be considered a serious issue with a number of other complications. For the treatment of this disease, prevention is the best method and to know about the complications is important because all of the factors involved in the incidence of durotomy should be considered while performing any kind of surgery

A Proposed Personalized Spine Care Protocol (SpineScreen) to Treat Visualized Pain Generators: An Illustrative Study Comparing Clinical Outcomes and Postoperative Reoperations between Targeted Endoscopic Lumbar Decompression Surgery, Minimally Invasive TLIF and Open Laminectomy.

Background: Endoscopically visualized spine surgery has become an essential tool that aids in identifying and treating anatomical spine pathologies that are not well demonstrated by traditional advanced imaging, including MRI. These pathologies may be visualized during endoscopic lumbar decompression (ELD) and categorized into primary pain generators (PPG). Identifying these PPGs provides crucial information for a successful outcome with ELD and forms the basis for our proposed personalized spine care protocol (SpineScreen). Methods: a prospective study of 412 patients from 7 endoscopic practices consisting of 207 (50.2%) males and 205 (49.8%) females with an average age of 63.67 years and an average follow-up of 69.27 months was performed to compare the durability of targeted ELD based on validated primary pain generators versus image-based open lumbar laminectomy, and minimally invasive lumbar transforaminal interbody fusion (TLIF) using Kaplan-Meier median survival calculations. The serial time was determined as the interval between index surgery and when patients were censored for additional interventional and surgical treatments for low back-related symptoms. A control group was recruited from patients referred for a surgical consultation but declined interventional and surgical treatment and continued on medical care. Control group patients were censored when they crossed over into any surgical or interventional treatment group. Results: of the 412 study patients, 206 underwent ELD (50.0%), 61 laminectomy (14.8%), and 78 (18.9%) TLIF. There were 67 patients in the control group (16.3% of 412 patients). The most common surgical levels were L4/5 (41.3%), L5/S1 (25.0%), and L4-S1 (16.3%). At two-year f/u, excellent and good Macnab outcomes were reported by 346 of the 412 study patients (84.0%). The VAS leg pain score reduction was 4.250 ± 1.691 (p < 0.001). No other treatment during the available follow-up was required in 60.7% (125/206) of the ELD, 39.9% (31/78) of the TLIF, and 19.7% (12/61 of the laminectomy patients. In control patients, only 15 of the 67 (22.4%) control patients continued with conservative care until final follow-up, all of which had fair and poor functional Macnab outcomes. In patients with Excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients (p < 0.001). The overall survival time in control patients was eight months with a standard error of 0.942, a lower boundary of 6.154, and an upper boundary of 9.846 months. In patients with excellent Macnab outcomes, the median durability was 62 months in ELD, 43 in TLIF, and 31 months in laminectomy patients versus control patients at seven months (p < 0.001). The most common new-onset symptom for censoring was dysesthesia ELD (9.4%; 20/206), axial back pain in TLIF (25.6%;20/78), and recurrent pain in laminectomy (65.6%; 40/61) patients (p < 0.001). Transforaminal epidural steroid injections were tried in 11.7% (24/206) of ELD, 23.1% (18/78) of TLIF, and 36.1% (22/61) of the laminectomy patients. The secondary fusion rate among ELD patients was 8.8% (18/206). Among TLIF patients, the most common additional treatments were revision fusion (19.2%; 15/78) and multilevel rhizotomy (10.3%; 8/78). Common follow-up procedures in laminectomy patients included revision laminectomy (16.4%; 10/61), revision ELD (11.5%; 7/61), and multilevel rhizotomy (11.5%; 7/61). Control patients crossed over into ELD (13.4%), TLIF (13.4%), laminectomy (10.4%) and interventional treatment (40.3%) arms at high rates. Most control patients treated with spinal injections (55.5%) had excellent and good functional outcomes versus 40.7% with fair and poor (3.7%), respectively. The control patients (93.3%) who remained in medical management without surgery or interventional care (14/67) had the worst functional outcomes and were rated as fair and poor. Conclusions: clinical outcomes were more favorable with lumbar surgeries than with non-surgical control groups. Of the control patients, the crossover rate into interventional and surgical care was 40.3% and 37.2%, respectively. There are longer symptom-free intervals after targeted ELD than with TLIF or laminectomy. Additional intervention and surgical treatments are more often needed to manage new-onset postoperative symptoms in TLIF- and laminectomy compared to ELD patients. Few ELD patients will require fusion in the future. Considering the rising cost of surgical spine care, we offer SpineScreen as a simplified and less costly alternative to traditional image-based care models by focusing on primary pain generators rather than image-based criteria derived from the preoperative lumbar MRI scan.