Multilevel Posterior Lumbar Research Articles

Implementing enhanced recovery after surgery protocol in elderly patients following multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases.

Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management strategy. The aim of the present study was to analyze the clinical efficacy of ERAS in elderly patients (> 70 years old) undergoing multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases. Patients older than 70 years undergoing multi-level lumbar or thoracolumbar instrumented fusion for degenerative disk diseases or spinal stenosis from January 2017 to December 2018 (non-ERAS group) and from January 2020 to December 2021 (ERAS group) were enrolled in present study. Patient-specific and procedure-specific clinical characteristics were collected. Univariate and multivariate regression were performed to determine the risk factors related to length of stay (LOS) and complications. A total of 233 patients were enrolled in this study, 70 in non-ERAS group and 163 in ERAS group. There were comparable baseline characteristics between groups. Further there were no significant differences in 90-day readmission rates and complication rates. However, we observed a significant reduction in LOS (14.89 ± 7.78 days in non-ERAS group versus 11.67 ± 7.26 days in ERAS group, p = 0.002) and overall number of complications (38 in non-ERAS group versus 58 in ERAS group, p = 0.008). Univariate linear regression denoted that operation time (p < 0.001), intraoperative blood loss (p < 0.001), intraoperative blood transfusion (p < 0.001), fusion number ≥ 5 (p < 0.001), spinal surgery including the thoracic spine (p < 0.001), CCI > 2 (p = 0.018), ERAS (p = 0.003) and spinal surgery including lumbar (p = 0.030) were associated with LOS. Furthermore, multivariate linear regression showed that ERAS (p = 0.001), CCI > 2 (p = 0.014), and Fusion number ≥ 5 (p = 0.002) were independent risk factors for LOS. Analogously, univariate logistic regression revealed that longer operation time (p = 0.005), more intraoperative blood loss (p < 0.001), more intraoperative blood transfusion (p = 0.001), fusion number ≥ 5 (p = 0.001), ERAS (p = 0.004) and spinal surgery including thoracic spine (p = 0.002) were related to complications, while implementing ERAS was associated with less complications. Multivariate logistic regression denoted that implementation of ERAS (p = 0.003), Intraoperative blood loss (p = 0.003) and Fusion number ≥ 5 (p = 0.008) were independent risk factors for postoperative complications. In conclusion, the present study reported the first ERAS principles performed in multi-level lumbar or thoracolumbar instrumented fusion for degenerative conditions. Our outcomes shown that the implementation of ERAS in these populations is favorable for reducing LOS and decreasing overall number of complications though the comparable complication rates between two groups. Totally, our ERAS protocols were safe and feasible in these populations.

Comparison of transforaminal and posterior lumbar interbody fusion outcomes in patients receiving a novel allograft versus rhBMP-2: a radiographic and patient-reported outcomes analysis.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been demonstrated to achieve the highest rates of arthrodesis in multilevel lumbar fusion but is also associated with possible perioperative morbidity. A novel allograft (OSTEOAMP) is a differentiated allograft that retains growth factors supporting bone healing. The authors sought to compare the clinical and radiographic outcomes of rhBMP-2 and the novel allograft in lumbar interbody arthrodesis to determine if the latter may be a safer and equally effective alternative to rhBMP-2 for single- and multilevel posterior or transforaminal lumbar interbody fusion (PLIF or TLIF). Patients who underwent single- or multilevel TLIF or PLIF using either OSTEOAMP or rhBMP-2 at the authors' institution over a 2-year period were prospectively followed for 12 months. Healthcare utilization, safety measures, patient satisfaction, physical disability (measured on the Oswestry Disability Index [ODI]), back and leg pain (on the numeric rating scale [NRS]), quality of life (on the EQ-5D scale), and return to work (RTW) were prospectively recorded. For purposes of this study, this consecutive series was retrospectively analyzed and pseudarthrosis rates were assessed at 2 years of follow-up. All patients (100%) had both 12-month patient-reported outcome follow-up and 24-month clinical and radiographic follow-up. One thousand one hundred fifty-four patients (654 treated with OSTEOAMP, 500 with rhBMP-2) were prospectively enrolled in the institutional registry. After propensity score matching, there were no significant baseline differences between 330 novel allograft and 330 rhBMP-2 cases. Perioperative morbidity and 90-day hospital readmission (3.3% vs 2.4%, p = 0.485) did not significantly differ between the novel allograft and the rhBMP-2 cases. At the 2-year follow-up, symptomatic pseudarthrosis requiring revision surgery occurred in 8 patients (2.4%) with OSTEOAMP and 6 patients (1.8%) with rhBMP-2 (p = 0.589). The overall fusion rate at 2 years was similar between groups (p = 0.213). Both groups showed significant and equivalent improvement in patient-reported outcome measures (PROMs) from baseline to 12-month follow-up, with no significant difference in 1-year mean NRS leg pain score (2.5 vs 2.7), ODI (25 vs 26), quality-adjusted life years (0.73 vs 0.73), satisfaction (83% vs 80%), or RTW (6.6 vs 7 weeks). In the authors' institutional experience, OSTEOAMP is a clinically viable substitute for rhBMP-2 for single- and multilevel lumbar fusion. This novel allograft provides clinically effective arthrodesis and improvements in PROMs comparable to rhBMP-2 with a similar safety profile. Additional indications and outcome assessment in longitudinal studies are needed to further characterize this allogeneic graft.

Addition of Ketorolac to Local Anesthesia for Wound Infiltration in Multilevel Posterior Lumbar Spinal Fusion: A Randomized, Double-Blinded, Placebo-controlled Trial.

Randomized double-blind controlled trial. The purpose of this study was to determine the efficacy of pain control and opioid consumption after administration of ketorolac directly to paraspinal muscle after spinal fusion. Ketorolac is added to multimodal analgesia regimens to improve pain control, reduce opioid consumption following Orthopaedics and spine surgery. However, evidence of efficacy of adding ketorolac to local anesthesia for intrawound infiltration after spine surgery is still limited. The patients who underwent multilevel lumbar decompression and posterolateral fusion were recruited and randomized to the control group which received 0.5% bupivacaine hydrochloride injected into paraspinal muscles before wound closure, and the ketorolac group which received 30mg ketorolac in addition to 0.5% bupivacaine hydrochloride. Post-operative numerical rating scale (NRS) for back pain, leg pain, morphine consumption, and adverse events were recorded. A total of 47 patients were randomized (24 in the ketorolac group and 23 in the control group). The mean age was 60.9±6.9 years old. The mean NRS for back pain at 6 hours after surgery was 5.8±3.0 points for the control group and 3.3±2.1 points for the ketorolac group (P<0.01). The ketorolac group consumed lesser morphine than the control group by 9.1mg in the first 24 hours, 13.8mg at 48 hours, 14.3mg at 72 hours, and 13.9mg at 96 hours after the surgery (P<0.05). Post-operative complications were not different between the two groups. The addition of ketorolac to bupivacaine for wound infiltration after posterior lumbar spine decompression and fusion reduces early post-operative pain and total morphine consumption as compared to bupivacaine alone.

The Impact of Improved Compliance With Enhanced Recovery After Surgery on Frail Patients Undergoing Multi-Level Posterior Lumbar Fusion Surgery for Degenerative Lumbar Diseases.

Patients with frailty are more prone to have perioperative adverse events, and enhanced recovery after surgery (ERAS) has been widely adopted to improve perioperative outcomes. The purpose of this study was to assess the impact of improved compliance with ERAS on perioperative outcomes in frail patients. Geriatric patients (over 65 years) who underwent multi-level lumbar fusion surgery between June 2017 and June 2022 were included. The patients were divided into two groups according to their degree of compliance with the ERAS. Stepwise nearest-neighbor propensity score matching 1:1 cohorts for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classfication and Charlson Comorbidity Index (CCI) was performed between groups, namely frail-compliant (FC), frail-noncompliant (FN). Further length of stay (LOS), complications and clinical efficacy were compared between groups. There were 83 pairs of well-balanced patients with comparable clinical baseline data. It was worth noting that patients in FC group has significant lower overall complications (20.5% in the FC group vs 39.8% in the FN group, P = 0.007), major complications (7.2% in the FC group vs 19.3% in the FN group, P = 0.022) and shorter LOS (11.18 ± 5.32 in the FC group vs 14.45 ± 4.68 in the FN group, P < 0.001) than patients in FN group. In addition, the initial occurrence of ambulation (2.14 ± 1.21 in FC group vs 3.18 ± 1.73 in FN group, P = 0.012) and bowel movement (3.68 ± 1.24 in FC group vs 4.17 ± 1.32 in FN group, P = 0.031) were earlier for patients in FC group than patients in FN group. With regard to clinical efficacy, there were no significant difference between FC and FN group in terms of patients who meet minimal clinical important difference (MCID) for Oswestry Disability Index (ODI) at postoperative day (POD) 30, Visual Analog Scale (VAS) for back at POD 30-90 and VAS for legs at POD 30, 90, and 180 follow-up intervals. However, there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 between FC and FN group. In this retrospective cohort study, we found that frail patients with higher ERAS adherence group had a lower incidence of overall complication, mjor complications, and a shorter LOS than their lower ERAS adherence counterparts. In addition, frail patients with higher ERAS adherence had earlier ambulatioin and bowel movement. More importantly, we found there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 in higher ERAS adherence than their lower counterparts.

Whether intraoperative hydrogen peroxide irrigation is effective in reducing blood loss and surgical site infection after multilevel posterior lumbar fusion surgery: A prospective case-control study of 2400 patients

Whether intraoperative hydrogen peroxide irrigation is effective in reducing blood loss and surgical site infection after multilevel posterior lumbar fusion surgery: A prospective case-control study of 2400 patients

177. Whether intraoperative hydrogen peroxide irrigation reduces blood loss and surgical site infection after multilevel posterior lumbar surgery: a prospective case-control study of 2,400 patients

177. Whether intraoperative hydrogen peroxide irrigation reduces blood loss and surgical site infection after multilevel posterior lumbar surgery: a prospective case-control study of 2,400 patients

Effectiveness of intraoperative table modification for achieving lumbar lordosis in multilevel lumbar fusion surgery: a propensity score-matched study

Background In multilevel posterior lumbar interbody fusion (PLIF) with posterior screw fixation, obtaining sufficient lumbar lordosis (LL) is difficult, especially in patients with osteoporosis. We performed intraoperative table modification (TM) using gravitational dropping of the patient’s lumbar spine, to improve restoration of LL. Methods We retrospectively reviewed the medical records of patients who underwent three- or four-level PLIF between 2005 and 2019. One hundred eleven patients were enrolled, with 96 patients receiving non-TM-PLIF and 15 patients receiving TM-PLIF. Radiological parameters, including segmental lordosis (SL), LL, sacral slope (SS), pelvic incidence, and pelvic tilt, were measured. Clinical outcomes were measured using a visual analogue scale (VAS) for the back and leg preoperatively and at the last follow-up. Additionally, the correlation between the bone mineral density (BMD) and the radiological parameters was calculated for TM-PLIF. We performed propensity score matching between the groups to control the baseline difference. Results We found a statistically better correction between immediate and last follow-up postoperative SL (p = 0.04), as well as between preoperative and last follow-up SL (p < 0.01) in the TM-PLIF group compared to that in the non-TM-PLIF group. VAS for the back and leg were not significantly different between the two groups. Additionally, the efficacy of lordosis correction in the TM-PLIF group showed a statistically significant negative correlation between BMD and the SS change both before and after the surgery (rho = −0.60, p = 0.02). Conclusion Whilst further study is required to conclusively establish its efficacy, TM-PLIF (table modification using gravitational dropping) shows potential advantages for restoring and maintaining LL in multilevel lumbar fusion, particularly in cases with low BMD.

Whether intraoperative hydrogen peroxide irrigation reduces blood loss and surgical site infection after multilevel posterior lumbar surgery: A prospective case-control study of 2400 patients

Whether intraoperative hydrogen peroxide irrigation reduces blood loss and surgical site infection after multilevel posterior lumbar surgery: A prospective case-control study of 2400 patients

Variability in wound closure technique in midline posterior lumbar fusion surgery. International survey and standardized closure technique proposal.

Surgical wound complications represent an important risk factor, particularly in multilevel lumbar fusions. However, the literature regarding optimal wound closure techniques for these procedures is limited. We performed an online survey of 61 spinal surgeons from 11 countries, involving 25 different hospitals. The study included 26 neurosurgeons, 21 orthopedists, and 14 residents (Neurosurgery - 6 and orthopedics 8). The survey contained 17 questions on demographic information, closure techniques, and the use of drainage in posterior lumbar fusion surgery. We then developed a "consensus technique." The proposed standardized closure techniques included: (1) using subfascial gravity drainage (i.e., without suction) with drain removal for <50 ml/day or a maximum duration of 48 h, (2) paraspinal muscle, fascia, and supraspinous ligament closure using interrupted-X stitches 0 or 1 Vicryl or other longer-lasting resorbable suture (i.e., polydioxanone suture), (3) closure of subcutaneous tissue with interrupted inverted Vicryl 2-0 sutures in two planes for subcutaneous tissue greater >25 mm in depth, and (4) skin closure with simple interrupted nylon 3-0 sutures. There is great variability between closure techniques utilized for multilevel posterior lumbar fusion surgery. Here, we have described various standardized/evidence-based proven techniques for the closure of these wounds.

Short-Term Impact of Bracing in Multi-Level Posterior Lumbar Spinal Fusion.

Clinical practice in postoperative bracing after posterior lumbar spine fusion (PLF) is inconsistent between providers. This paper attempts to assess the effect of bracing on short-term outcomes related to safety, quality of care, and direct costs. Retrospective cohort analysis of consecutive patients undergoing multilevel PLF with or without bracing (2013-2017) was undertaken (n = 980). Patient demographics and comorbidities were analyzed. Outcomes assessed included length of stay (LOS), discharge disposition, quality-adjusted life years (QALY), surgical-site infection (SSI), total cost, readmission within 30 days, and emergency department (ED) evaluation within 30 days. Amongst the study population, 936 were braced and 44 were not braced. There was no difference between the braced and unbraced cohorts regarding LOS (P = .106), discharge disposition (P = .898), 30-day readmission (P = .434), and 30-day ED evaluation (P = 1.000). There was also no difference in total cost (P = .230) or QALY gain (P = .740). The results indicate a significantly lower likelihood of SSI in the braced population (1.50% versus 6.82%, odds ratio = 0.208, 95% confidence interval = 0.057-0.751, P = .037). There was no difference in relevant comorbidities (P = .259-1.000), although the braced cohort was older than the unbraced cohort (63 versus 56 y, P = .003). Bracing following multilevel posterior lumbar fixation does not alter short-term postoperative course or reduce the risk for early adverse events. Cost analysis show no difference in direct costs between the 2 treatment approaches. Short-term data suggest that removal of bracing from the postoperative regimen for PLF will not result in increased adverse outcomes.

Impact of Discharge to Rehabilitation on Postdischarge Morbidity Following Multilevel Posterior Lumbar Fusion.

This was a retrospective cohort study. The objective of this study was to compare 30-day postdischarge morbidity for 3-or-more level (multilevel) posterior lumbar fusion in patients who were discharged to home versus rehabilitation. Spine surgery has been increasingly performed in the elderly population, with many of these patients being discharged to rehabilitation and skilled nursing facilities. However, research evaluating the safety of nonhome discharge following spine surgery is limited. Patients who underwent multilevel posterior lumbar fusion from 2005 to 2018 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Regression was utilized to compare primary outcomes between discharge disposition and to evaluate for predictors thereof. We identified 5276 patients. Unadjusted analysis revealed that patients who were discharged to rehabilitation had greater postdischarge morbidity (5.6% vs. 2.6%). After adjusting for baseline differences, discharge to rehabilitation no longer predicted postdischarge morbidity [odds ratio (OR)=1.409, confidence interval: 0.918-2.161, P=0.117]. Multivariate analysis also revealed that age (P=0.026, OR=1.023), disseminated cancer (P=0.037, OR=6.699), and readmission (P<0.001, OR=28.889) independently predicted postdischarge morbidity. Thirty days morbidity was statistically similar between patients who were discharged to home and rehabilitation. With appropriate patient selection, discharge to rehabilitation can potentially minimize 30-day postdischarge morbidity for more medically frail patients undergoing multilevel posterior lumbar fusion. These results are particularly important given an aging population, with a great portion of elderly patients who may benefit from postacute care facility discharge following spine surgery.

Addition of ketorolac to local anesthesia for wound infiltration before closure in multilevel posterior lumbar spinal fusion: A randomized controlled trial

Addition of ketorolac to local anesthesia for wound infiltration before closure in multilevel posterior lumbar spinal fusion: A randomized controlled trial

Risk of adjacent segment disease after 'topping-off' multi-level lumbar fusions with posterior dynamic stabilisers: an observational cohort study.

To determine whether 'topping-off' lumbar fusions, using posterior dynamic stabilising devices (PDSs) with specific biomechanical parameters, reduces the risk of adjacent segment disease (ASD). Survival analysis of two non-randomised cohorts, with or without 'topping-off' (T/O or NoT/O), compared the risk of further surgery for ASD following multi-level posterior lumbar interbody fusion (PLIF). The study sample comprised consecutive patients, aged 55 + years, with degenerative pathology at 2, 3 or 4 levels. The NoT/O cohort underwent surgery between August 1993 and September 2019 (n = 425) and the T/O cohort between September 2011 and September 2019 (n = 146). Comparison of ASD risk between cohorts used Cox proportional hazards (CPH) modelling and Kaplan-Meier survivorship analysis. Analysis was completed on 571 operations across 507 patients. Median follow-up was 63months (range 0.3-196) and 37months (range 1.7-98) for the NoT/O and T/O cohorts, respectively. Of 423 patients, 125 (29.6%) patients in the NoT/O cohort underwent further surgery for ASD and 16/145 (11.03%) in the T/O cohort. The hazard ratio (T/O: NoT/O) from the CPH model was 0.42 (95% CL: 0.24-0.74, P = 0.003). Mean annual incidence across the first 5years was 5.0% in the NoT/O cohort compared with 2.8% in the T/O cohort (P = 0.029). No patient required surgery or developed ASD at a 'topped-off' level. Two patients developed asymptomatic pedicle screw loosening at the level of the PDS device. PROMs were similar between cohorts. This large, non-randomised, observational study found an approximately 60% reduction in further surgery for ASD with the use of the PDS to 'top-off' PLIF fusions. PDS device-related complications were very low.

188. The safety and efficacy of hydrogen peroxide in controlling blood loss and surgical site infection after multi-segmental lumbar spine surgery: a retrospective, case-controlled study of 2,626 patients

BACKGROUND CONTEXT Multiple-level lumbar fusion surgery is associated with prolonged duration of surgery and significant blood loss, which are deemed significant risk factors for postoperative SSI. Controlling the blood loss and improving local resistance to pathogens is extremely valuable to reduce perioperative complications, including SSI, and speed up recovery after surgery. Concerns regarding the safety profile of TXA, whether it increases the incidence of thromboembolic events, such as deep vein thrombosis (DVT), pulmonary embolism (PE), and myocardial infarctions (MI), have been raised frequently, especially for the patients who have accompanying cardiovascular and cerebrovascular diseases, which are relatively common in patients with degenerative spinal disease. Additionally, it is strongly debated whether the usage of vancomycin powder can induce culture-negative seroma formation and affect bone healing. Hydrogen peroxide (H2O2) is an inexpensive and readily available option whose hemostatic and antiseptic properties have been separately confirmed in several previous studies. However, whether H2O2 can integrate the advantages of vancomycin and TXA in controlling blood loss and postoperative SSI simultaneously after lumbar spine surgery has not been explored, neither have its complications. PURPOSE This study aimed to explore the safety and efficacy of H2O2 in controlling blood loss and SSI after multi-segmental lumbar spine surgery. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE A total of 2,626 patients who underwent multi-segmental lumbar spinal surgery between January 2015 and January 2018 were included in this study. According to whether H2O2 irrigation was applied, they were divided into control group (1,345 patients) and experimental group (1,281 patients).The inclusion criteria were: (1) patients were diagnosed with thoracic and/or lumbar degenerative diseases, such as spinal canal stenosis, disc herniation, spondylolisthesis, and/or degenerative scoliosis; (2) patients treated with multilevel (operated level > 2) posterior lumbar interbody fusion (PLIF) with or without posterolateral fusion. The exclusion criteria were: patients diagnosed with spinal fracture-dislocation, infection, tuberculosis, tumor, congenital spinal deformity or received revision surgery; patients with a coagulation or hemoglobin dysfunction before surgery; dura tear accompanied by cerebrospinal fluid leakage detected intraoperatively; the perioperative use of hemostatic agents such as TXA or treatment with antifibrinolytic drugs. OUTCOME MEASURES The primary outcome evaluated was the incidence of SSI. The definition of SSI including superficial and deep infection after lumbar spinal surgery was derived from the guidelines published by the U.S. Centers for Disease Control and Prevention. Superficial infection is defined as occurring within 30 days after surgery, involving only the incision skin and subcutaneous tissue. Deep infection is defined as occurring within 1 year after operation, characterized by superficial infection, the involving fascia and myometrium. Besides the demographic parameters, the laboratory examination results and surgery related information such as operative time, numbers of operated levels, intraoperative blood loss, postoperative drainage, postoperative SSI and extubation time were recorded. The perioperative complications including pneumocephalus, symptomatic DVT, PE and MI were included in the evaluation. METHODS A standard posterior midline incision and exposure was applied; and irrigation with 1 L of saline was performed before skin closure in all patients. For the experimental group, the incision was soaked with 50 mL of 3% H2O2 solution for 30 s before the saline irrigation. RESULTS No significant differences were seen regarding demographic parameters, laboratory examination results, comorbidities and surgical related information. The extubation time and postoperative drain collection were lower in the experimental group (3.6±0.5 days vs 4.1±0.6, p=0.402; 251.8±67.5 vs 291.8±71.3, p=0.013). In the control group, the rate of SSI was 2.4% (32/1345), including 17 superficial wound infections and 15 deep wound infections. In the experimental group, the SSI rate was 1.4% (18/1281), including 15 patients with superficial wound infection and three with deep wound infection. Staphylococcus aureus was the most common organism, especially in the experimental group (66.7% vs 50%). There was no significant difference between both groups in the perioperative complications such as hematencephalon, DVT, PE and MI (p>0.05, respectively). Pneumocephalus was not observed in either group. CONCLUSIONS The application of H2O2 in PLIF does not increase the perioperative complications such as hematencephalon, DVT, PE, MI, and especially pneumocephalus; it also reducing the blood loss and SSI after surgery, which is quite promising for patients with a high risk of thromboembolic events and beneficial for controlling the increasing number of vancomycin-resistant bacteria. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical Outcomes of Multilevel Posterior Lumbar Interbody Fusion versus Lateral Lumbar Interbody Fusion for the Correction of Adult Spinal Deformity: A Comparative Clinical Study

Study DesignA retrospective case control study.PurposeThe purpose of this study was to compare the surgical outcomes of multilevel lateral lumbar interbody fusion (LIF) and multilevel posterior lumbar interbody fusion (PLIF) in the surgical treatment of adult spinal deformity (ASD) and to evaluate the sagittal plane correction by combining LIF with posterior-column osteotomy (PCO).Overview of LiteratureThe surgical outcomes between multilevel LIF and multilevel PLIF in ASD patients remain unclear.MethodsWe retrospectively reviewed 31 ASD patients who underwent multilevel LIF combined with PCO (LIF group, n=14) or multilevel PLIF (PLIF group, n=17) and with a minimum 2-year follow-up. In the comparison between LIF and PLIF groups, their mean age at surgery was 69.4 vs. 61.8 years while the mean follow-up period was 29.2 vs. 59.3 months. We evaluated the transition of pelvic incidence–lumbar lordosis (PI–LL) and disc angle (DA) in the LIF group, in fulcrum backward bending (FBB), after LIF and after posterior spinal fusion (PSF) with PCO. The spinopelvic radiographic parameters were compared between LIF and PLIF groups.ResultsCompared with the PLIF group, the LIF group had less blood loss and comparable surgical outcomes with respect to radiographic data, health-related quality of life scores and surgical time. In the LIF group, the mean DA and PI–LL were unchanged after LIF (DA, 5.8°; PI–LL, 15°) compared with the values using FBB (DA, 4.3°; PI–LL, 15°) and improved significantly after PSF with PCO (DA, 8.1°; PI–LL, 0°).ConclusionsIn the surgical treatment of ASD, multilevel LIF is less invasive than multilevel PLIF and combination of LIF and PCO would be necessary for optimal sagittal correction in patients with rigid deformity.

Pedicle Screw Fixation in Single-Level, Double-Level, or Multilevel Posterior Lumbar Fusion for Osteoporotic Spine: A Retrospective Study with a Minimum 2-Year Follow-Up

Pedicle screw loosening is a common postoperative complication for osteoporotic patients, and several studies have identified the important role of fusion length in internal fixation failure, but the relationship between the number of fusion segments and the potential risks remains unclear. This study aimed to investigate the rate and risk factors of screw loosening in osteoporotic patients with different levels of degenerative lumbar disease. The total cohort of 217 patients was divided into 3 groups according to the different fusion levels: single-level (group A; 100 cases), double-level (group B; 73 cases), and multilevel group (group C; 44 cases). Patient baseline demographic characteristics and assessments with a visual analog scale (VAS) and the Oswestry Disability Index (ODI) before operation and at the last follow-up were compared among the 3 groups. Compared with preoperative values, VAS and ODI scores at the last follow-up were significantly improved in all 3 groups. Operative time, blood loss, length of hospital stay, screw loosening rate, fusion rate, and VAS and ODI scores at the last follow-up obviously increased with the increasing number of fusion segments (group C> group B> group A). Of note, all the screw loosening was observed in cranial and caudal vertebra. Furthermore, multivariate logistic regression analysis identified lumbosacral fixation, larger pelvic incidence (PI)-lumbar lordosis (LL) difference (PT-LL), and greater postoperative pelvic tilt (PT) as independent predictors of screw loosening. However, sex, bone mineral density, body mass index, LL, sacral slope, PI, the change in LL, and preoperative PT were not relevant to screw loosening (P > 0.05). Owing to the high rate of screw loosening in cranial and caudal vertebra, osteoporotic patients with double-level or multilevel pedicle screw fixation benefited less than those with single-level pedicle screw fixation. Larger PI-LL, larger PT, and lumbosacral fixation are other risk factors for screw loosening. An instrument with stronger holding strength at cranial and caudal pedicle screws is recommended for those high-risk patients.

Retracted: Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders.

We have retracted this publication because we were informed that an image used by the authors was copied from the following article: J Korean Neurosurg Soc. 2011 Nov; 50(5): 441-445. Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System: Technical Tips, Surgical Outcomes (https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3259464/pdf/jkns-50-441.pdf) (https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3259464/). Reference: 1. Xiaoyang Liu, Guangrun Li, Jiefeng Wang, Heqing Zhang: Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders. Med Sci Monit, 2015; 21: 3652-3657. DOI: 10.12659/MSM.894890.

Preemptive analgesia with a single low dose of intrathecal morphine in multilevel posterior lumbar interbody fusion surgery: a double-blind, randomized, controlled trial

Patients undergoing lumbar spinal surgery may experience considerable pain in the early postoperative period, and poor pain control after multilevel lumbar spinal fusion surgery is frequently associated with multiple complications and delayed discharge from hospital. The current study evaluated the efficacy and safety of preemptive analgesia with intrathecal morphine (ITM) in patients undergoing multilevel posterior lumbar spinal fusion surgery. Double-blinded, randomized, controlled trial. Ninety-two patients aged between 18 and 80 years who were scheduled to undergo elective lumbar laminectomy (L3-S1) and dual-level fusions. The primary endpoint was the degree of postoperative pain at rest and during movement evaluated using a 10-point visual analogue scale. The secondary outcomes included the consumption of analgesics, the patient-assessed postoperative and satisfaction scores, adverse effects, time to first ambulation, and length of hospital stay. Patients were randomly allocated to either the ITM group that received 0.2 mg of ITM or the control (CON) group that received 2 ml of 0.9% saline as a skin infiltration 30 minutes prior to anesthesia induction. The ITM group had a significantly lower visual analogue scale score than the CON group during the first 3 days postoperatively (at rest, P=0.000, during movement, P=0.000). The ITM group used significantly less sufentanil than the CON group in the first 3 days postoperatively (p=.000) in patient-controlled intravenous analgesia, as well as in supplemental analgesic demands. The ITM group reported a greater degree of satisfaction with the whole hospitalization experience than the CON group (2.4±0.6 vs. 1.9±0.6, p=.000). The two groups did not significantly differ regarding adverse effects, length of hospital stay, and time taken to regain the ability to walk without support. Preemptive analgesia with ITM results in significantly improved early postoperative pain control and decreased postoperative patient-controlled intravenous analgesia consumption, with no increase in adverse effects.

The clinical and radiological outcomes of multilevel posterior lumbar interbody fusion in the treatment of degenerative scoliosis: a consecutive case series with minimum 2 years follow up.

Surgical treatment for adult degenerative scoliosis (ADS) is a complex undertaking and is associated with a high complication rate. Our aim was to evaluate the clinical and radiological outcomes, mortality and morbidity of multilevel posterior lumbar interbody fusion (MPLIF) in the treatment in ADS based on the experience of a single tertiary referral center for spinal surgery. We performed a retrospective analysis of prospectively collected data of consecutive patients who had undergone multi-level posterior interbody fusion for degenerative scoliosis. We prospectively recorded patients' demographics, co-morbidities; coronal and sagittal plane deformity assessment and surgical details: number of instrumented levels, and intra-operative and postoperative complications. Functional outcomes and patient-reported complications were entered in our local spine surgery database (part of the Eurospine Spine Tango Registry) and used to collect data on functional scores and patient-reported complications preoperatively and at 6, 12 and 24 months' follow-up. Our study involved 13 males and 51 females with a mean age of 70.26 (range 49-90, SD 8.9). MPLIF was performed at five levels in one patient, four levels in 29 patients, three levels in 20 patients, and two levels in 14 patients. There were a total of 14 (21.87%) major, minor and mechanical complications. There were no procedure-related mortalities. The average COMI and Eq5d scores improved significantly post-surgery, and this improvement was maintained at a mean follow-up of up to two years. Multilevel posterior interbody fusion is a safe procedure, and in selected cases can result in good clinical and radiological outcomes with improvement in patient quality of life.

Risk factors for upper adjacent segment degeneration after multi-level posterior lumbar spinal fusion surgery

BackgroundPosterior lumbar spinal fusion has been widely used in degenerative lumbar stenosis, but adjacent segment degeneration (ASD) was common. Researchers have found many risk factors for ASD after one or two levels of surgery, but few clinical studies focused on multi-level surgery. The purpose of this study was to clarify risk factors for upper ASD after multi-level posterior lumbar spinal fusion.MethodsA retrospective study was performed on the clinical data of 71 patients with degenerative lumbar stenosis who underwent multi-level (at least 3 levels) posterior lumbar spinal fusion from January 2013 to December 2016. Two groups were divided according to lamina and posterior ligamentous complex (PLC) maintenance of proximal fixed vertebrae in surgery. In the 22 patients of group A, the proximal fixed vertebral lamina and PLC were not resected, and in the 49 patients of group B, the proximal fixed vertebral lamina and PLC were resected completely. Age, sex, body mass index (BMI), number of fixed vertebrae and fused levels, spinopelvic parameters, coronal Cobb angle, and modified Pfirrmann grading system were measured for each patient. A Cox proportional hazards model was used to analyze risk factors for upper ASD.ResultsNo symptomatic ASD was found during the follow-up period. Patients who underwent proximal fixed vertebral lamina and PLC resection had a significantly higher percentage of radiographic ASD (P = 0.042). The Cox proportional hazards model showed that age, sex, BMI, preoperative lumbar lordosis, sacral slope, pelvic tilt, coronal Cobb angle, number of fixed vertebrae, and interbody fusion levels had no significant differences for radiographic ASD. But a preoperative modified Pfirrmann grade higher than 3, a high degree of preoperative pelvic incidence, and more decompressed levels had statistical significance (P = 0.024, 0.041, and 0.008, respectively).ConclusionsA preoperative modified Pfirrmann grade higher than 3, a high degree of preoperative pelvic incidence, and more decompressed levels might be risk factors for upper radiographic ASD after multi-level posterior lumbar spinal fusion surgery.