Lumbar Decompression Research Articles

Influence of Posture on Gait Parameters in Severe Symptomatic Lumbar Stenosis Before and After Decompression Surgery

BackgroundWe searched to quantify the influence of sagittal vertical axis (SVA) on the improvement of spatiotemporal gait parameters using a gait motion analysis (GMA) before and after decompression surgery in patients suffering from lumbar stenosis (LSS). MethodsThirty-nine patients with severe LSS planned for lumbar decompression underwent a full body biplanar radiographs (EOS®) to quantify the SVA, and have benefited from a three-dimensional GMA one month before surgery (M0) and 6 month (M6) after surgery. The first step of this study was to confirm the validation of three dimensional SVA (3D SVA) for posture analysis. An analysis of modification of the 3D SVA and spatio-temporal gait parameters was then carried out in order to identify any correlation. ResultsDecompression surgery did not significantly improve 3D SVA between M0 and M6 (respectively 49.1 (50.3) versus 49.84 (19.02), p=0.42). Concerning spatio-temporal parameters, we found significant difference for all parameters between M0 and M6. A strong correlation (R2>0.65) between static SVA (EOS®) and 3D SVA was demonstrated using a statistical regression equation. There was also a statistically significant correlation between SVA (static and 3D) and improvement in spatiotemporal gait parameters after decompression surgery. ConclusionThis study analyses the relationship between postural change (SVA) and improvement in gait parameters measured during GMA before and after decompression surgery for lumbar spinal stenosis. This specific analysis of gait parameters may represent a prognostic assessment tool for the recovery of patients undergoing surgery for a lumbar spinal stenosis.

The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome.

Background and objective Cauda equina syndrome (CES) is considered a surgical emergency, and its primary treatment involves decompression of the nerve roots, typically in the form of discectomy or laminectomy. The primary aim of this study was to determine the complication, reoperation, and readmission rates within 30 days of surgical treatment of CES secondary to disc herniation by using the PearlDiver database (PearlDiver Technologies, Colorado Springs, CO). The secondary aim was to assess preoperative risk factors for a higher likelihood of complication occurrence within 30 days of surgery for CES. Methods A total of 524 patients who had undergone lumbar discectomy or laminectomy for CES were identified. The outcome measures were 30-day reoperation rate for revision decompression or lumbar fusion, and 30-day readmissions related to surgery. The patient data collected included medical history and surgical data including the number of levels of discectomy and laminectomy. Results Based on our findings, intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities were significant risk factors for readmission to the hospital within 30 days following surgery for CES. The most common postoperative complications were as follows: visits to the emergency department (63 patients, 12%), surgical site infection (21 patients, 4%), urinary tract infection (14 patients, 3%), and postoperative anemia (11 patients, 2%). Conclusions In the 30-day period following lumbar decompression for cauda equina syndrome, our findings demonstrated an 8% reoperation rate and 17% readmission rate. Although CES is considered an indication for urgent surgery, gaining awareness about reoperation, readmission, and complication rates in the immediate postoperative period may help calibrate expectations and inform medical decision-making.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review.

Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression. To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis. Retrospective review. Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years. The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery. Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors. A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively. Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Lumbar Spinal Stenosis and Minimally Invasive Lumbar Decompression: A Narrative Review.

Lumbar spinal stenosis (LSS) is a common pain condition that causes lumbar back pain, radiating leg pain, and possible functional impairment. MILD is an emerging minimally invasive treatment for LSS. It is an image-guided percutaneous procedure designed to debulk hypertrophied ligamentum flavum. However, the exact short- and long-term efficacy, safety profile, indication criteria, and certain procedure details reported in medical literature vary. This narrative review was to elucidate efficacy, safety profile, certain procedure details, advantages, and limitations of MILD. This is a narrative review. All included articles are clinic trials including analytic studies and descriptive studies. PubMed, Cochrane Library, and Scopus were searched. Only clinical trials of MILD procedure were included. Information of indications, contraindications, VAS scores, ODI scores, effective rate, efficacy durations, and certain procedure details was focused on. According to the literature, for the MILD procedure, the VAS score could be reduced from a pre-treatment level of 6.3-9.6 to a post-treatment level of 2.3-5.8. The ODI score could be reduced from a pre-treatment level of 38.8-55.3 to a post-treatment level of 27.4-39.8. The effective rate of the MILD procedure was reported to be 57.1%-88%. A 2-year postoperative stability of efficacy was also supported. One RCT study testified superior efficacy of MILD over epidural steroid injection. There is few high-quality literature in the review. Moreover, the long-term efficacy of MILD cannot be revealed according to the current literature. Based on the reviewed literature, MILD is an effective and safe procedure. MILD can reduce pain intensity and improve functional status significantly. Therefore, it is a preferable option for LSS patients who failed conservative treatments, but not for those who require immediate invasive decompression surgery.

Spontaneous Thoracic Dural Tear Presenting With Postural Headache: A Case Report

BACKGROUND: Incidental dural tear (durotomy) is a known complication of many forms of spinal instrumentation. The majority of durotomy cases are due to a known traumatic force, such as an intentional durotomy during neuraxial anesthesia, or an unintentional tear during lumbar decompression surgery. However, spontaneous dural tears have occasionally been reported. CASE REPORT: We report a case of a 16-year-old woman with postural headaches who was found to have a spontaneous thoracic dural tear on magnetic resonance imaging. She underwent a successful fluoroscopic-guided epidural blood patch with resolution of symptoms. CONCLUSION: This case highlights the importance of considering spontaneous dural tears as a possible cause of postural headaches. KEY WORDS: Spontaneous dural tear, traumatic dural tear, idiopathic dural tear, durotomy, post-dural postural headache, epidural blood patch, headache, CSF leak, case report

Impact of American Society of Anesthesiologists' Classification on Postoperative Satisfaction and Clinical Outcomes Following Lumbar Decompression: Cohort-Matched Analysis.

Retrospective cohort. The aim was to compare patient-reported outcomes (PROMs), minimum clinically important difference (MCID) achievement, and postoperative satisfaction following minimally invasive lumbar decompression in patients stratified by American Society of Anesthesiologists (ASA) classification. Some guidelines recommend against performing elective procedures for patients with an ASA score of 3 or greater; however, long-term postoperative outcomes are not well described. Primary, single-level, minimally invasive lumbar decompression procedures were identified. PROMs were administered at preoperative, 6-week, 12-week, 6-month, 1-year, 2-year timepoints and included Patient-Reported Outcomes Measurement Information System-Physical Function, visual analog scale (VAS) back/leg, Oswestry disability index (ODI), and 12-item short form physical component score. Satisfaction scores were collected postoperatively for VAS back/leg, ODI, and individual ODI subcategories. Patients were grouped (ASA<3, ASA≥3), and propensity scores were matched to control for significant differences. Demographic and perioperative characteristics were compared using χ 2 and the Student's t test. Mean PROMs and postoperative satisfaction were compared at each time point by a 2-sample t test. Postoperative PROM improvement from the preoperative baseline within each cohort was calculated with a paired t test. MCID achievement was determined by comparing ΔPROMs to established thresholds and comparing between groups using simple logistic regression. One hundred and twenty-nine propensity-matched patients were included: 99 ASA<3 and 30 ASA≥3. No significant demographic differences were observed between groups. ASA≥3 patients experienced significantly increased length of stay and postoperative narcotic consumption on surgery day ( P <0.048, all). Mean PROMs and MCID achievement did not differ. The ASA<3 cohort significantly improved from the preoperative baseline for all PROMs at all postoperative time points. ASA<3 patients demonstrated higher levels of postoperative satisfaction at 6 weeks for VAS leg, VAS back, ODI, sleeping, lifting, walking, standing, sex, travel, and at 6 months for VAS back ( P <0.045, all). ASA≥3 patients may achieve similar long-term clinical outcomes to ASA<3 patients, though they may show poorer short-term satisfaction for disability, leg pain, and back pain, which could be related to differing preoperative expectations.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery

Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P= 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P= 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P= 0.5944) between the 2 groups. For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.

Evaluation of the Use of Monopolar Low-Temperature Plasma Electrode in Lumbar Spinal Canal Expansion, Decompression, Bone Grafting, and Fusion Internal Fixation Surgery

Objective: This study aims to explore the therapeutic effects of using a monopolar low-temperature plasma electrode and a high-frequency electrotome during lumbar spinal canal expansion, decompression, bone grafting, and fusion internal fixation surgery. The study also investigates the impact of these techniques on inflammatory indicators and quality of life in patients. Methods: A total of 100 patients with lumbar spondylolisthesis treated between June (January) 2022 and July (March) 2023 were selected for this study. They were randomly divided into a control group and an observation group, with 50 cases in each group. Both groups underwent lumbar spinal canal expansion, decompression, bone grafting, and fusion internal fixation surgery. The control group used a high-frequency electrotome during surgery, while the observation group used a monopolar low-temperature plasma electrode. Surgical indicators (operation time, intraoperative blood loss), inflammatory indicators, pain levels, and quality of life were compared between the two groups. Results: The operation time in the observation group was shorter than that in the control group (P&lt;0.05). Postoperative levels of TNF-α and CRP were lower in the observation group than in the control group (P&lt;0.05). The observation group had lower VAS scores and higher SF-36 scores compared to the control group (P&lt;0.05). Conclusion: The use of a monopolar low-temperature plasma electrode in lumbar spinal canal expansion, decompression, bone grafting, and fusion internal fixation surgery yields positive therapeutic outcomes. It effectively reduces operation time, alleviates patient's inflammatory responses and pain levels, aids in postoperative recovery, and enhances quality of life. These results suggest the potential for wider adoption.

The Unilateral Biportal Endoscopic Technique for Treatment of Lumbar Spinal Stenosis: Early Surgical Results

Objective: Minimally invasive (MI) surgery for the treatment of spinal stenosis is currently a topic of substantial interest. One such technique is the unilateral biportal endoscopic (UBE) method, becoming popular among spine surgeons as a MI alternative to decompressive lumbar laminectomy without fusion. The purpose of this study was to present a description of the surgical technique and early clinical and radiological outcomes following the author's adoption of the UBE surgical technique for decompression of spinal stenosis.Methods: Between 2019 and 2021, surgery was performed on 47 patients with lumbar spinal stenosis. Clinical and radiological data were retrospectively analyzed through electronic medical records and imaging software reviews. Questionnaires and radiologic images were prospectively collected at scheduled times. The surgical technique used two corridors: one for endoscopic viewing and the other for handling surgical instruments during the procedure. Clinical outcomes were measured using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI), while radiological outcomes were evaluated using X-rays to assess instability. Outcomes after UBE surgery were evaluated in terms of changes in clinical and radiological parameters from the baseline. A mixed-effects model with random effects for patients and surgical levels was used to test for differences in repeatedly measured clinical and radiological parameters.Results: During the early postoperative period, there were few complications, and all patients had a smooth recovery. Patients reported minimal postoperative wound discomfort. Back and leg VAS scores improved significantly in the early postoperative period (at 3, 6, and 12 months) compared to the baseline preoperative scores (p&lt;0.001). The ODI also showed significant improvement post-operatively (p&lt;0.001). The X-ray parameters were well maintained and did not show any progression of instability during the follow-up period.Conclusion: UBE surgery is a safe and effective MI technique for treating lumbar stenosis, with good early results and few complications during the early learning curve period.

Efficacy of percutaneous lumbar decompression and interspinous spacers.

Efficacy of percutaneous lumbar decompression and interspinous spacers.

Exploring elderly patients’ experiences and concerns about early mobilization implemented in postoperative care following lumbar spinal surgery: a qualitative study

BackgroundGiven its apparent benefits, early mobilization is becoming increasingly important in spinal surgery. However, the time point at which patients first get out of bed for mobilization after spinal surgery varies widely. Beginning in January 2022, we conducted a study of early mobilization (mobilization within 4 h postoperatively) following multi-segment lumbar decompression and fusion surgery in elderly patients. The study goal was to better understand elderly patients’ perceptions of early mobilization and ultimately contribute to the improvement of elderly patients’ perioperative experiences and quality of life.MethodsWe employed a qualitative descriptive study design involving face-to-face semi-structured interviews. Forty-five consecutive patients were invited, among whom 24 were enrolled and completed the qualitative investigation from February to June 2022. Of these 24 patients, 10 underwent early mobilization (mobilization within 4 h postoperatively) and 14 underwent mobilization at ≥ 24 h postoperatively. Three researchers conducted a 15-question interview the day before each patient’s discharge. The interviews were audio-recorded, and content analysis was used to assess the data.ResultsSix themes regarding the patients’ experiences and concerns about early mobilization were identified: worries, benefits, daily routines, pain, education, and support. The study results revealed the obstacles in early mobilization practice and highlighted the importance of perioperative education on early mobilization.ConclusionsClear and explicit guidance on early mobilization and a multidisciplinary mobilization protocol that incorporates a comprehensive pain management plan are essential for effective patient education. These measures may have positive effects on reducing patients’ stress and anxiety regarding postoperative early mobilization.

Serum antioxidant enzymes in spinal stenosis patients with lumbar disc herniation: correlation with degeneration severity and spinal fusion rate

ObjectiveTo determine whether superoxide dismutase (SOD) and glutathione reductase (GR) correlated with the intervertebral disc degeneration (IDD) severity and the postoperative spinal fusion rate in lumbar spinal stenosis patients accompanied with lumbar disc herniation.MethodsThis retrospective study investigated 310 cases of posterior lumbar decompression and fusion. The cumulative grade was calculated by adding the pfirrmann grades of all the lumbar discs. Subjects were grouped based on the median cumulative grade. Logistic regression was used to determine the associations among the demographical, clinical, and laboratory indexes and severe degeneration and fusion. The receiver operating characteristic (ROC) curve was performed to measure model discrimination, and Hosmer-Lemeshow (H-L) test was used to measure calibration.ResultsSOD and GR levels were significantly lower in the severe degeneration group (cumulative grade > 18) than in the mild to moderate degeneration group (cumulative grade ≤ 18). Furthermore, the SOD and GR concentrations of the fusion group were significantly higher than that of the non-fusion group (p < 0.001 and p = 0.006). The multivariate binary logistic models revealed that SOD and GR were independently influencing factors of the severe degeneration (OR: 0.966, 95%CI: 0.950–0.982, and OR: 0.946, 95%CI: 0.915–0.978, respectively) and non-fusion (OR: 0.962; 95% CI: 0.947–0.978; OR: 0.963; 95% CI: 0.933–0.994). The models showed excellent discrimination and calibration. Trend analysis indicated that the levels of SOD and GR tended to decrease with increasing severity (p for trend < 0.001 and 0.003). In addition, it also revealed that SOD provided protection from non-fusion in a concentration-dependent manner (p for trend < 0.001). However, GR concentration-dependent effects were not apparent (p for trend = 0.301).ConclusionHigh serum SOD and GR levels are associated with a better fusion prognosis and a relief in degeneration severity.

Effect of Lower Extremity Osteoarthritis on Outcomes of Lumbar Decompression.

The purpose of this study is to evaluate how hip or knee osteoarthritis (OA) and total joint arthroplasty impact the outcomes of patients undergoing lumbar decompression. A retrospective review of 342 patients undergoing lumbar decompression without fusion from January 2019 and June 2021 at a single institution was performed. Univariate and multivariate analyses were used to compare outcomes between patients with and without concomitant hip or knee OA. Forty-six percent of patients had a hip or knee OA diagnosis and were higher risk as they were older, had higher BMIs, were more likely to be former smokers, had higher ASA scores, and were more likely to undergo 3+ level surgery. Postoperatively, after adjusting for differences between groups, hip or knee OA patients were more likely to be readmitted (OR=12.45, p=0.026) or have a complication (OR=13.77, p=0.031). However, patient reported outcomes as measured by Patient Reported Outcomes Measurement Information System-physical function. were similar at 1-3 months and 3-6 months. Higher levels of physical function were observed at 3-6 months postoperatively in hip OA patients with a history of THA. Patients with concomitant hip or knee OA are at higher risk for readmission and postoperative complications but may achieve similar levels of physical function as those without OA.

Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis.

Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs. The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed. No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period. The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

Hospital cost differences between open and endoscopic lumbar spine decompression surgery.

In recent years, fully endoscopic decompression surgery for degenerative spine disease has become increasingly popular in the US. Although an endoscopic approach has demonstrated some benefits compared with open procedures in randomized controlled trials, the cost of advanced technologies remains contested. The authors evaluated the differences in costs and cost drivers between open and endoscopic decompression surgical procedures performed at a single institution. Using associated Current Procedural Terminology codes, the authors identified all open and endoscopic decompression lumbar surgical procedures performed from January 1, 2016, through December 31, 2022. Preoperative comorbidities, surgical characteristics, and postoperative outcomes were captured. The costs of index surgery-related readmission for revision, washout, or other complications were included in the index surgery expenses. Associated in-hospital costs were collected; these were reported in comparative percentages with open surgical procedures as the baseline because of an institutional agreement. Univariate and multivariate analyses were performed. The retrospective search identified 633 open surgical procedures and 195 endoscopic surgical procedures for inclusion. The two patient cohorts were similar, with clinically nonrelevant but statistically significant differences in mean age (open 55.7 years vs endoscopic 59.4 years, p = 0.01) and mean American Society of Anesthesiologists physical status class (open 2.3 vs endoscopic 2.4, p = 0.03). Postoperatively, patients who underwent open surgical procedures had significantly longer mean hospital stays (open 1.4 days vs endoscopic 0.7, p < 0.01) and more perioperative complications (open 7.9% of patients vs endoscopic 3.1%, p = 0.02), and they required washout surgical procedures in some cases (open 1.3% vs endoscopic 0%, p = 0.12). The largest cost difference between open and endoscopic surgical procedures was the significantly greater cost of disposable supplies for endoscopic cases (10.1% vs 31.7% of the total cost of open procedures, p < 0.01), and open surgical procedures were generally less costly in total (100.0% vs 115.1%, p < 0.01). In multivariate linear regression, endoscopic surgery was independently associated with greater total costs (standardized beta 15.9%, p < 0.01), although length of hospital stay (standardized beta 34.0%) and readmissions (standardized beta 30.0%, p < 0.01) had larger effects on cost. The endoscopic approach was associated with greater total in-hospital costs compared with open procedures. The findings of further cost evaluations, including those of patient-reported outcomes, social cost, and capital costs per procedure type, need to be included in operational and clinical decisions.

Perspective; high frequency of intraoperative errors due to extreme, oblique, and lateral lumbar interbody fusions (XLIF, OLIF, LLIF): Are they "safe"?

Extreme Lateral Lumbar Interbody Fusions (XLIF), Oblique Lateral Interbody Fusion (OLIF,) and Lateral Lumbar Interbody Fusion (LLIF) were largely developed to provide indirect lumbar decompressions for spinal stenosis, deformity, and/or instability. Here, we have reviewed and updated the incidence of intraoperative errors attributed to XLIF, OLIF, and LLIF. Specifically, we focused on how often these procedures caused new neurological deficits, major vessel, visceral, and other injuries, including those warranting secondary surgery. Performing XLIF, OLIF, and LLIF can lead to significant intraoperative surgical errors that include varying rates of; new neurological injuries (i.e. iliopsoas motor deficits (4.3-19.7-33.6-40%), proximal hip/upper thigh sensory loss/dysesthesias (5.1% to 21.7% to 40%)), life-threatneing vascular injuries (i.e., XLIF (0% - 0.4%-1.8%), OLIF (3.2%), and LLIF (2%) involving the aorta, iliac artery, inferior vena cava, iliac vein, and segmental arteries), and bowel/viscarl injuries (0.03%-0.4%) leading to reoperations (i.e., XLIF (1.8%) vs. LLIF (3.8%) vs. XLIF/LLIF/OLIF 2.2%)). Varying reports documented that XLIF, OLIF and LLIF caused up to a 40% incidence of new sensory/motor deficits, up to a 3.2% incidence of major vascular insults, a 0.4% frequency of visceral/bowel perforations, and a 3.8% need for reoperations. These high frequencies of intraoperative surgical errors attributed to XLIF, OLIF, and LLIF should prompt reconsideration of whether these procedures are "safe."

Effect of Preoperative Marijuana on Patient Outcomes and Opioid Use after Lumbar Decompression.

Retrospective Cohort Study. Our study aims to analyze the effect of preoperative marijuana use on outcomes and postoperative opioid use in patients who have undergone lumbar decompression without fusion. All patients >18years of age who underwent lumbar decompression from 2017-2022 with documented preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match incorporating demographics, procedure type, and levels decompressed was performed to compare preoperative marijuana users and non-users. 1-year preoperative and postoperative opioid consumption in milligrams of morphine equivalents and postoperative outcomes including readmissions, reoperations, and complications, were obtained. A multivariate regression model was performed to measure the effect of marijuana use on the likelihood of a spine reoperation. Of the 340 included patients, 85 were preoperative marijuana users. There were no significant differences in medical complications, 90-day readmissions, or opioid consumption preoperatively or postoperatively (P > .05). We identified a trend towards patients who used marijuana having more reoperations for any cause (20.0% vs 11.37%, P = .067). Multivariate logistic regression analysis suggested that preoperative marijuana use was a significant predictor of all-spine reoperations (OR = 2.06, P = .036). In lumbar decompression patients, preoperative marijuana use does not impact opioid consumption, readmissions, or medical complications, but is a significant predictor of future postoperative reoperations. Additional research is necessary to further explore the role of marijuana use in spine surgery.

Revisional Endoscopic Foraminal Decompression via Modified Interlaminar Approach at L5-S1 after Failed Posterior Instrumented Lumbar Fusion in Elderly Patients.

Elderly people usually have poorer surgical tolerance and a higher incidence of complications when undergoing revision surgery after posterior instrumented lumbar fusion (PILF). Full-endoscopic transforaminal surgery is a safe and effective option, but sometimes, it is difficult to revise L5-S1 foraminal stenosis (FS) after PILF. Therefore, we developed full-endoscopic lumbar decompression (FELD) at the arthrodesis level via a modified interlaminar approach under local anesthesia. This study aimed to describe the technical note and clinical efficacy of the technique. Eleven patients with unilateral lower limb radiculopathy after PILF underwent selective nerve root block and then underwent FELD. Magnetic resonance imaging (MRI) and computer tomography (CT) were performed on the second postoperative day. Their clinical outcomes were evaluated with a Visual analog scale (VAS) of low back pain and sciatica pain, Oswestry disability index (ODI), and the MacNab score. Complete decompression was achieved in every case with FELD without serious complications. Postoperative VAS of sciatica pain and ODI at each time point and VAS of low back pain and ODI after three months postoperatively were significantly improved compared with those preoperative (p < 0.05). According to the MacNab criteria, seven patients (63.6%) had excellent results at the two-year follow-up, and four patients (36.4%) had good results. No patients required further revision surgery. FELD, via a modified interlaminar approach, is effective for treating unilateral L5-S1 FS after PILF in elderly people.

When Does Intervention End and Surgery Begin? The Role of Interventional Pain Management in the Treatment of Spine Pathology.

Recent advances in the field of interventional pain management (IPM) involve minimally invasive procedures such as percutaneous lumbar decompression, interspinous spacer placement, interspinous-interlaminar fusion and sacroiliac joint fusion. These developments have received pushback from surgical professional societies, who state spinal instrumentation and arthrodesis should only be performed by spine surgeons. The purpose of this review is to evaluate the validity of this claim. A literature search was conducted on Google Scholar and PubMed databases. Articles were included which examined IPM in the following contexts: credentialing and procedural privileging guidelines, fellowship training and education, and procedural outcomes compared to those of surgical specialties. Our primary research question is: "Should interventionalists be performing decompression and fusion procedures?". Advanced percutaneous spine procedures are not universally incorporated into pain fellowship curriculums. Trainees attempt to compensate for these deficiencies through industry-led training, which has been criticized for lacking central regulation. There is also a paucity of studies comparing procedural outcomes between surgeons and interventionalists for complex spine procedures, including decompression and fusion. Pain fellowship curriculums have not kept pace with some of procedural advancements within the field. Interventionalists are also not trained to manage potential complications of spinal instrumentation and arthrodesis, which has been recognized as an essential requirement for procedural privileging. Decompression and fusion may therefore be outside the scope of an interventionalist's practice.

General Versus Nongeneral Anesthesia for Spinal Surgery: A Comparative National Analysis of Reimbursement Trends Over 10 Years.

Nongeneral anesthesia (non-GA) spine surgery is growing in popularity and has facilitated earlier postoperative recovery, reduced cost, and fewer complications compared with spine surgery under general anesthesia (GA). Changes in reimbursement policies have been demonstrated to correlate with clinical practice; however, they have yet to be studied for GA vs non-GA spine procedures. We aimed to investigate trends in physician reimbursement for GA vs non-GA spine surgery in the United States. We queried the ACS-NSQIP for GA and non-GA (regional, epidural, spinal, and anesthesia care/intravenous sedation) spine surgeries during 2011-2020. Work relative value units per operative hour (wRVUs/h) were retrieved for decompression or stabilization of the cervical, thoracic, and lumbar spine. Propensity score matching (1:1) was performed using all baseline variables. We included 474 706 patients who underwent spine decompression or stabilization procedures. GA was used in 472 248 operations, whereas 2458 operations were non-GA. The proportion of non-GA spine operations significantly increased during the study period. Operative times ( P < .001) and length of stays ( P < .001) were shorter in non-GA when compared with GA procedures. Non-GA lumbar procedures had significantly higher wRVUs/h when compared with the same procedures performed under GA (decompression; P < .001 and stabilization; P = .039). However, the same could not be said about cervicothoracic procedures. Lumbar decompression surgeries using non-GA witnessed significant yearly increase in wRVUs/h ( P < .01) contrary to GA ( P = .72). Physician reimbursement remained stable for procedures of the cervical or thoracic spine regardless of the anesthesia. Non-GA lumbar decompressions and stabilizations are associated with higher and increasing reimbursement trends (wRVUs/h) compared with those under GA. Reimbursement for cervical and thoracic surgeries was equal regardless of the type of anesthesia and being relatively stable during the study period. The adoption of a non-GA technique relative to the GA increased significantly during the study period.