Numeric Rating Scale Back Pain Research Articles

Incidence of revision surgery and patient-reported outcomes within 5 years of the index procedure for grade 1 spondylolisthesis: an analysis from the Quality Outcomes Database spondylolisthesis data.

Some patients treated surgically for grade 1 spondylolisthesis require revision surgery. Outcomes after revision surgery are not well studied. The objective of this study was to determine how revision surgery impacts patient-reported outcomes (PROs) in patients undergoing decompression only or decompression and fusion (D+F) for grade 1 spondylolisthesis within 5 years of the index surgery. Patients in the 12 highest Quality Outcomes Database (QOD) enrolling sites with a diagnosis of grade 1 spondylolisthesis were identified and the incidence of revision surgery between the decompression-only and D+F patients were compared. PROs were compared between cohorts requiring revision surgery versus a single index procedure. Of 608 patients enrolled, 409 had complete 5-year data available for this study. Eleven (13.3%) of 83 patients underwent revision in the decompression-only group as well as 32 (9.8%) of 326 in the D+F group. For the entire cohort, patients requiring revision had significantly worse PROs at 5 years: Oswestry Disability Index (ODI) 27.4 versus 19.4, p = 0.008; numeric rating scale for back pain (NRS-BP) 4.1 versus 3.0, p = 0.013; and NRS for leg pain (NRS-LP) 3.4 versus 2.1, p = 0.029. In the decompression-only group, the change in 5-year PROs was not impacted by revision status: ODI 31.9 versus 24.2, p = 0.287; NRS-BP 1.9 versus 2.9, p = 0.325; and NRS-LP 6.2 versus 3.7, p = 0.011. In the D+F group, the change in 5-year PROs was diminished if patients required revision: ODI 19.1 versus 29.1, p = 0.001; NRS-BP 3.0 versus 4.0, p = 0.170; and NRS-LP 2.3 versus 4.6, p = 0.001. The most common reasons for reoperation within 5 years in the decompression-only group were repeat decompression and instability, whereas in the D+F group the most common reason was adjacent-segment disease. The need for revision resulted in modestly diminished benefit compared with patients with no revisions. These differences were greater in the fusion cohort compared with the decompression-only cohort. The mean PRO improvement still far exceeded minimal clinically important difference thresholds for all measures for patients who underwent a revision surgery.

The impact of smoking on patient-reported outcomes following lumbar decompression: an analysis of the Quality Outcomes Database.

Smoking has been shown to negatively impact spinal health, as well as the outcomes of spinal fusion. Published reports show conflicting data regarding whether smoking negatively impacts patient outcomes following lumbar decompression. The objective of this study was to investigate whether smoking affects the outcomes of patients undergoing lumbar decompression for spinal stenosis or herniated disc. The Quality Outcomes Database was queried for patients with spinal stenosis or lumbar disc herniation who underwent one- or two-level lumbar decompression without fusion. All patients had preoperative and 12-month outcome measures and were divided into groups of nonsmokers and current smokers. Outcomes were compared between the two groups, as well as the percentage of patients reaching the minimal clinically important difference (MCID) threshold for numeric rating scale (NRS) back and leg pain scores and the Oswestry Disability Index (ODI). Of 17,271 patients, 14,233 were nonsmokers and 3038 were current smokers. Smokers had worse baseline NRS back and leg pain, ODI, and EQ-5D scores and experienced slightly less improvement in all measures following lumbar decompression (p ≤ 0.009), although changes were largely similar, and a high percentage of patients achieved the MCID thresholds for NRS back pain (78% nonsmokers vs 75% smokers), NRS leg pain (79% nonsmokers vs 73% smokers), and ODI (74% nonsmokers vs 68% smokers). Comparison of propensity-matched cohorts did not identify any difference in outcomes in smokers versus nonsmokers. In patients undergoing lumbar decompression for spinal stenosis or herniated disc, smokers demonstrated slightly less improvement in outcomes compared with nonsmokers, and a high proportion of both groups achieved meaningful improvement with surgery. While smoking cessation should be strongly encouraged in all patients, lumbar decompression procedures for spinal stenosis and herniated disc should not be denied to smokers.

Clinical Importance of Redundant Nerve Roots in Patients with Symptomatic Lumbar Spinal Stenosis: A Secondary Analysis of NORDSTEN Spinal Stenosis Trial Data.

Post-hoc analysis of data from a randomized clinical trial. To compare preoperative symptoms of patients with lumbar spinal stenosis (LSS) with and without redundant nerve roots (RNR), and to compare the change in clinical outcomes between those two groups 2 years after decompression surgery. RNR are often seen on MRI in patients with spinal stenosis. Previous studies have reported that patients with RNR are older and have worse symptoms at baseline. A meta-analysis from 2018 concluded that this radiological sign could be seen as a negative predictor of outcome. High quality prospective studies are lacking. Patient characteristics and reported pain and function scores were compared between LSS groups with (RNR+) and without RNR (RNR-) at baseline and after 2 years follow-up. Primary outcome was the mean change in the Oswestry Disability Score (ODI). Secondary outcomes included mean change in scores of the Zurich Claudication Questionnaire (ZCQ) and the numeric rating scale (NRS) for leg and back pain. Out of 416 patients included in the present analysis, 163 (39%) had RNR at baseline. Both groups were similar in regard to patient age, smoking habits, BMI and duration of symptoms. Both groups also showed similar pain and function scores at baseline. The RNR+ group contained a significantly higher proportion of men, patients with severe stenosis and multiple stenotic levels on MRI. At 2-year follow-up the mean change of ODI was -22.1 in the RNR+ group and -17.4 in RNR- group (mean difference 4.7 (95%CI 1.3-8.2) P=0.007). Statistically significant differences were also found for secondary outcomes ZCQ, and NRS leg and back pain favouring the RNR+ group. Patients with RNR had similar baseline characteristics and similar symptoms as patients without. RNR before surgery were associated with better clinical improvement 2 years after decompression.

Expectations in patients undergoing spine surgery are high and unmet

BACKGROUND CONTEXTDefining success in spine surgery lacks a standardized approach, and all existing concepts are based on registrations after surgery. PURPOSETo examine patients’ expectations before spine surgery assessed by a modified Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS). The authors asked: how do the expectations align with actual outcomes and can a patient's individual expectations be used as a success criterion in itself? STUDY DESIGN /SETTINGProspective single-center study. PATIENT SAMPLEPatients scheduled for spine surgery at Akershus University Hospital (AHUS) were included in the study. They underwent 1 of 3 procedures: decompression for spinal stenosis, disc removal for lumbar disc herniation, or spinal fusion for degenerative disc disease. OUTCOME MEASURESModified and standard version of ODI and NRS (back and leg pain). METHODSPreoperatively, the patients were given a modified ODI and NRS questionnaire in which they were asked to register the minimum acceptable functional impairment and pain they anticipated to have postsurgery. The patients’ expectations were compared with 3-and 12-month follow-up data from the Norwegian Registry for Spine Surgery (NORspine) with ODI, NRS and Global Perceived Effect (GPE) scale. We used simple descriptive statistics. RESULTSA total of 93 patients completed the pre-op questionnaire. Of these, 65 responded to the 3-month follow-up and 53 at 12-month follow-up. The mean (95%CI) ODI before surgery was 38.3 (34.2–42.3), the mean (95% CI) preoperative NRS back pain was 6.34 (5.81–6.88), and leg pain was 6.67 (6.08–7.26). The patients expected a mean (95% CI) ODI of 10.5 (7.5–13.5), mean (95%CI) NRS back pain of 2.5 (2.1–3.0), and NRS leg pain of 1.8 (1.5–2.2). The actual clinical outcome after 12 months were a mean (95% CI) ODI of 21.7 (17.0–26.5), NRS back pain of 3.4 (2.8–4.1), and leg pain of 2.8 (2.0–3.5). Only 12 (30.8%) patients achieved their expected ODI, while 26 (65.0%) classified themselves as significantly better according to GPE. CONCLUSIONSPatients seem to have high expectations before spine surgery, and the expectations may exceed the clinical outcome. Only 30.8% had their ODI expectations met, but perceived benefit was higher. High expectations may be due to inadequate preoperative information and/or the unsuitability of ODI for capturing expectations.

Outcome of intradiscal condoliase injection therapy for patients with recurrent lumbar disc herniation.

Retrospective cohort study. This study aimed to compare data from patients who received intradiscal condoliase (chondroitin sulfate ABC endolyase) injection for primary lumbar disc herniation (LDH) and recurrent LDH. Chemonucleolysis with condoliase for LDH is a treatment with relatively good results and a high safety profile; however, few studies have reported recurrence after LDH surgery. The study participants were 249 patients who underwent intradiscal condoliase injection for LDH at nine participating institutions, including 241 patients with initial LDH (group C) and eight with recurrent LDH (group R). Patient characteristics including age, sex, body mass index, disease duration, intervertebral LDH level, smoking history, and diabetes history were evaluated. Low back pain/leg pain Numerical Rating Scale (NRS) scores and the Oswestry Disability Index (ODI) were used to evaluate clinical symptoms before treatment and at 6 months and 1 year after treatment. Low back pain NRS scores (before treatment and at 6 months and 1 year after treatment, respectively) in group C (4.9 → 2.6 → 1.8) showed significant improvement until 1 year after treatment. Although a tendency for improvement was observed in group R (3.5 → 2.8 → 2.2), no significant difference was noted. Groups C (6.6 → 2.4 → 1.4) and R (7.0 → 3.1 → 3.2) showed significant improvement in the leg pain NRS scores after treatment. Group C (41.4 → 19.5 → 13.7) demonstrated significant improvement in the ODI up to 1 year after treatment; however, no significant difference was found in group R (35.7 → 31.7 → 26.4). Although intradiscal condoliase injection is less effective for LDH recurrence than for initial cases, it is useful for improving leg pain and can be considered a minimally invasive and safe treatment method.

Impact of educational background on preoperative disease severity and postoperative outcomes among patients with lumbar spondylolisthesis: a Quality Outcomes Database study.

Deficiency in patient education has been correlated with increased disease-related morbidity and decreased access to care. However, the associations between educational level, preoperative disease severity, and postoperative outcomes in patients with lumbar spondylolisthesis have yet to be explored. The spondylolisthesis dataset of the Quality Outcomes Database (QOD)-a cohort with prospectively collected data by the SpineCORe study team of the 12 highest enrolling sites with an 81% follow-up at 5 years -was utilized and stratified for educational level. Patients were classified into three categories (high school or less, graduate, or postgraduate). Patient-reported outcome measures (PROMs) documented at baseline and follow-up included Oswestry Disability Index (ODI) score, EQ-5D in quality-adjusted life years, and numeric rating scale (NRS) scores for back and leg pain. Disease severity was measured with PROMs. Postoperatively, patients also completed the North American Spine Society assessment to measure their satisfaction with surgery. Multivariable regression analysis was used to compare education level with disease severity and postoperative outcomes. A total of 608 patients underwent analysis, with 260 individuals (42.8%) at an educational level of high school or less. On univariate analysis, baseline disease severity was worse among patients with lower levels of education. On multivariable regression analysis, patients with postgraduate level of education had significantly lower ODI scores (β = -3.75, 95% CI -7.31 to -0.2, p = 0.039) compared to graduates, while the other PROMs were not associated with significant differences at baseline. Five years postoperatively, patients from various educational backgrounds exhibited similar rates of minimal clinically important differences in PROMs. Nevertheless, patients with the lowest educational level had higher ODI scores (27.1, p < 0.01), lower EQ-5D scores (0.701, p < 0.01), and higher NRS leg pain (3.0, p < 0.01) and back pain (4.0, p < 0.01) scores compared to those with graduate or postgraduate levels of education. The odds for postoperative satisfaction were also comparable between cohorts at 5 years (reference, graduate level; high school or less, OR 0.87, 95% CI 0.46-1.64, p = 0.659; postgraduate, OR 1.6, 95% CI 0.7-3.65, p = 0.262). Lower patient education level was associated with a greater baseline disease severity in patients with lumbar spondylolisthesis. Surgery demonstrated similar benefits irrespective of educational background; however, individuals with lower educational level reported lower outcomes overall. This emphasizes the need for enhanced health literacy to mitigate disparities for reported outcomes.

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.

Improvement in Pain, Quality of Life, and Urinary Dysfunction following Correction of Lumbar Lordosis and Reduction in Lumbar Spondylolistheses Using Chiropractic BioPhysics® Structural Spinal Rehabilitation: A Case Series with >1-Year Long-Term Follow-Up Exams.

(1) Background: Lumbar spondylolisthesis affects ~20% of the US population and causes spine-related pain and disability. (2) Methods: This series reports on three patients (two females and one male) aged 68-71 years showing improvements in back pain, quality of life (QOL), and urinary dysfunction following correction of lumbar spondylolistheses using CBP® spinal rehabilitation. Pre-treatment radiographs showed lumbar hyperlordosis (-49.6°, ideal is -40°) and anterolisthesis (14.5 mm, ideal is 0 mm). Pre-treatment patient-reported outcome measures (PROMs) included a numeric rating scale (NRS) for back pain (7.3/10, ideal is 0), urinary urgency (8/10, ideal is 0), and SF-36 physical (PCS) and mental component score (MCS) (29.8 and 46.6, ideal is 46.8 and 52.8). Patients underwent 2-3 CBP® sessions per week to correct lumbar hyperlordosis and lumbar anterolistheses. (3) Results: Post-treatment radiographs showed improvements in lumbar curvature (-42.8°) and anterolisthesis (4.2 mm). Post-treatment PROMs showed improvements in NRS for back pain (1/10), urinary urgency (2.3/10), and SF-36 PCS and MCS (50.2 and 57.7). Long-term follow-up radiographs and PROMs showed maintained improvements. (4) Conclusions: This series documents the first-recorded long-term corrections of lumbar spondylolisthesis and concomitant improvements in back pain, urinary urgency, and QOL using CBP®. This series provides evidence for CBP® as a non-surgical approach to lumbar spinal rehabilitation and the possible impacts of spinal alignment on pain, urinary dysfunction, and QOL.

The impact of anxiety and depression on lumbar spine surgical outcomes: a Michigan Spine Surgery Improvement Collaborative study.

The presence of depression and anxiety has been associated with negative outcomes in spine surgery patients. While it seems evident that a history of depression or anxiety can negatively influence outcome, the exact additive effect of both has not been extensively studied in a multicenter trial. The purpose of this study was to investigate the relationship between a patient's history of anxiety and depression and their patient-reported outcomes (PROs) after lumbar surgery. Patients in the Michigan Spine Surgery Improvement Collaborative registry undergoing lumbar spine surgery between July 2016 and December 2021 were grouped into four cohorts: those with a history of anxiety only, those with a history of depression only, those with both, and those with neither. Primary outcomes were achieving the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System Physical Function 4-item Short Form (PROMIS PF), EQ-5D, and numeric rating scale (NRS) back pain and leg pain, and North American Spine Society patient satisfaction. Secondary outcomes included surgical site infection, hospital readmission, and return to the operating room. Multivariate Poisson generalized estimating equation models were used to report incidence rate ratios (IRRs) from patient baseline variables. Of the 45,565 patients identified, 3941 reported a history of anxiety, 5017 reported a history of depression, 9570 reported both, and 27,037 reported neither. Compared with those who reported having neither, patients with both anxiety and depression had lower patient satisfaction at 90 days (p = 0.002) and 1 year (p = 0.021); PROMIS PF MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p = 0.006); EQ-5D MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p < 0.001); NRS back pain MCID at 90 days (p < 0.001) and 1 year (p < 0.001); and NRS leg pain MCID at 90 days (p < 0.001), 1 year (p = 0.024), and 2 years (p = 0.027). Patients with anxiety only (p < 0.001), depression only (p < 0.001), or both (p < 0.001) were more likely to be readmitted within 90 days. Additionally, patients with anxiety only (p = 0.015) and both anxiety and depression (p = 0.015) had higher rates of surgical site infection. Patients with anxiety only (p = 0.006) and depression only (p = 0.021) also had higher rates of return to the operating room. The authors observed an association between a history of anxiety and depression and negative outcome after lumbar spine surgery. In addition, they found an additive effect of a history of both anxiety and depression with an increased risk of negative outcome when compared with either anxiety or depression alone.

Machine Learning Models for Predicting Disability and Pain Following Lumbar Disc Herniation Surgery

Lumber disc herniation surgery can reduce pain and disability. However, a sizable minority of individuals experience minimal benefit, necessitating the development of accurate prediction models. To develop and validate prediction models for disability and pain 12 months after lumbar disc herniation surgery. A prospective, multicenter, registry-based prognostic study was conducted on a cohort of individuals undergoing lumbar disc herniation surgery from January 1, 2007, to May 31, 2021. Patients in the Norwegian Registry for Spine Surgery from all public and private hospitals in Norway performing spine surgery were included. Data analysis was performed from January to June 2023. Microdiscectomy or open discectomy. Treatment success at 12 months, defined as improvement in Oswestry Disability Index (ODI) of 22 points or more; Numeric Rating Scale (NRS) back pain improvement of 2 or more points, and NRS leg pain improvement of 4 or more points. Machine learning models were trained for model development and internal-external cross-validation applied over geographic regions to validate the models. Model performance was assessed through discrimination (C statistic) and calibration (slope and intercept). Analysis included 22 707 surgical cases (21 161 patients) (ODI model) (mean [SD] age, 47.0 [14.0] years; 12 952 [57.0%] males). Treatment nonsuccess was experienced by 33% (ODI), 27% (NRS back pain), and 31% (NRS leg pain) of the patients. In internal-external cross-validation, the selected machine learning models showed consistent discrimination and calibration across all 5 regions. The C statistic ranged from 0.81 to 0.84 (pooled random-effects meta-analysis estimate, 0.82; 95% CI, 0.81-0.84) for the ODI model. Calibration slopes (point estimates, 0.94-1.03; pooled estimate, 0.99; 95% CI, 0.93-1.06) and calibration intercepts (point estimates, -0.05 to 0.11; pooled estimate, 0.01; 95% CI, -0.07 to 0.10) were also consistent across regions. For NRS back pain, the C statistic ranged from 0.75 to 0.80 (pooled estimate, 0.77; 95% CI, 0.75-0.79); for NRS leg pain, the C statistic ranged from 0.74 to 0.77 (pooled estimate, 0.75; 95% CI, 0.74-0.76). Only minor heterogeneity was found in calibration slopes and intercepts. The findings of this study suggest that the models developed can inform patients and clinicians about individual prognosis and aid in surgical decision-making.

Lumbar spinal stenosis and surgical decompression affect sleep quality and position in patients. A prospective cross-sectional cohort study

IntroductionIt is reasonable to assume that lumbar spinal stenosis (LSS) affects the cauda nerve roots also at night. Research questionDoes microsurgical decompression influence sleep quality and position? Materials and methodsA study nurse interviewed 140 patients scheduled for LSS decompression using the Pittsburgh Sleep Quality Index (PSQI), Spinal Stenosis Measure (SSM), Numeric Rating Scale (NRS) for back and leg pain, Douleur Neuropathique (DN4), and Charlson Comorbidity Index. Epidemiologic and MRI data were collected along with self-reported rankings of preferred sleep positions (prone, supine, side, and fetal). Follow-up interviews were conducted by telephone six and 18 months after discharge. Statistical analysis was performed using SSPS 24, with significance set at p < 0.05. Results132 patients (55% female, mean age 73 years) were evaluated. Preoperatively, 45 (34.1%) patients were classified as good sleepers (GS: PSQI ≤5, range 1–21 (worst)) and 87 (65.9%) as poor sleepers (PS: PSQI ≥6). Decompression surgery reversed the relationship between PS (31.8%) and GS (68.2%, recovered/improved). Protective fetal sleeping position was the most common (≥70%) before and after surgery for both PS and GS. Risk factors for PS included female sex (p = 0.03), obesity (p = 0.03), high NRS back pain score (p = 0.008), and high SSM symptom score (p = 0.004). MRI imaging did not differ between PS and GS. Discussion and conclusionLSS had a negative effect on sleep quality, whereas surgical decompression had a positive effect. The protective fetal sleeping position was the preferred position both before and after surgery.

Hydrogel Augmentation of the Lumbar Intervertebral Disc: An Early Feasibility Study of a Treatment for Discogenic Low Back Pain

PurposeTo assess the safety and effectiveness of intradiscal hydrogel in patients with chronic low back pain (CLBP) due to degenerative disc disease (DDD) refractory to conventional medical management. Materials and MethodsTwenty patients aged 22–69 years with numerical rating scale (NRS) pain of ≥4 were enrolled. All patients with CLBP resulting from DDD confirmed by imaging and discography received injections of hydrogel (Hydrafil Intervertebral Disc Augmentation; ReGelTec, Baltimore, Maryland) at 1 or 2 lumbar levels (29 levels treated) from August to December 2020. The primary safety end point was freedom from serious adverse events (SAEs). The primary performance end point was successful gel delivery into the desired disc. Patients were also assessed on the NRS as well as the Oswestry disability index (ODI). ResultsNineteen patients were followed up at a mean of 131 days, and 1 patient was lost to follow-up. Preliminary results showed significant reductions in median NRS back pain from 7 (range 4–10) to 1 (range 0–8) (P <.0001) and median ODI scores from 54 (range 22–58) to 2 (range 0–58) (P <.0001) at 6 months of follow-up. There were 5 SAEs, and 4 of the 2 were determined to be associated with treatment. ConclusionsThis early feasibility study showed that the hydrogel implant was safe with no persistently symptomatic SAEs, and demonstrated effectiveness with significant reduction in pain and improvement in function when used to treat painful DDD and CLBP.

Promotion of higher rates of early fusion using activated titanium versus polyetheretherketone cages in adults undergoing 1- and 2-level transforaminal lumbar interbody fusion procedures: a randomized controlled trial.

There is ongoing debate on the relative benefits and drawbacks of polyetheretherketone (PEEK) versus titanium (Ti) in generating a bone-to-implant surface microenvironment conducive to osseointegration. Micro- and nanoscale internal and topographic cage modifications have recently been posited to facilitate osseointegration and fusion, but human in vivo confirmation remains lacking. The authors of this study sought to directly compare early radiological outcomes in adults undergoing 1- and 2-level transforaminal lumbar interbody fusion (TLIF) procedures using either PEEK or nano-etched Ti interbody cages with an incorporated microlattice structure. Patients were enrolled in a single academic center using a single-blind randomized controlled superiority design. Screening was undertaken from a pool of consecutive patients eligible for TLIF to undergo placement in a 1:1 ratio of either lordotic PEEK or activated Ti cages at each level of 1- or 2-level procedures. An a priori power analysis was performed and a preplanned interim analysis was undertaken once 50 of 70 patients were enrolled. Patient study data were collected perioperatively and uploaded to a Research Electronic Data Capture (REDCap) registry. Interbody fusion was assessed based on 6-month postoperative lumbar dual-energy CT (DECT) studies using the method of Brantigan and Steffee, as modified to describe the Fraser definition of locked pseudarthrosis (Brantigan-Steffee-Fraser [BSF] scale). In the final cohort of 50 patients, 40 interbody levels implanted with PEEK cages were compared with 34 interbody levels with activated Ti cages. The trial was stopped early given the results of an interim analysis with respect to the primary outcome. Surgical parameters including number of levels treated, average cage height, and position were not different between groups. For the PEEK and activated Ti groups, 20.6% versus 84.0% demonstrated BSF grade 3 fusion on 6-month postoperative DECT imaging (p < 0.001). Subsidence at 6 months on DECT was identified in 12 (41.4%) of PEEK levels versus 5 (20.8%) of activated Ti levels (p < 0.001). BSF-3 grading was predictive of segmental stability and numeric rating scale (NRS) leg pain improvement at 1 year postoperatively. Oswestry Disability Index and NRS back and leg pain scores all improved similarly in both cohorts at 1 year postoperatively. Activated Ti interbody cages mediate early fusion at significantly higher rates with lower rates of subsidence as compared with PEEK cages. These findings support the idea that interbody cage microscale properties, including surface topography, may play a primary role in facilitating osseointegration and fusion.

403 Inferior Clinical Outcomes for Patients with Medicaid Insurance Following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients

INTRODUCTION: It remains unclear how type of insurance coverage impacts long-term, spine-specific patient-reported outcomes (PROs). METHODS: The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. 24-month PROs compared included Oswestry Disability Index (ODI), Numeric Rating Scale Back Pain (NRS-BP), NRS Leg Pain (NRS-LP), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Satisfaction. RESULTS: 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319, 52.5%), Medicare (n = 235, 38.7%), Medicaid (n = 36, 5.9%), and VA/government (n =17, 2.8%). 1 patient (0.2%) was uninsured and was removed from the analyses. In adjusted multivariable analyses, when compared to patients with private insurance, Medicaid was associated with worse 24-month postoperative ODI β = 10.2, 95% CI 3.9 - 16.5) and NRS-LP β = 1.3, 95% CI 0.3 - 2.4). Medicaid was associated with worse EQ-5D scores compared to private insurance (β = -0.07, 95% CI -0.01 - -0.14), but not when compared to Medicare and VA/government insurance (p &gt; 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (OR = 0.2, 95% CI 0.03 - 0.7) compared to VA/government insurance. NRS-BP and NASS satisfaction did not differ by insurance coverage (p &gt; 0.05). CONCLUSIONS: Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs following lumbar spondylolisthesis surgery compared to other payer types. While all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.

Outcomes of surgical intervention for degenerative lumbar spondylolisthesis: a comparative analysis of different surgical fixation techniques.

Debate regarding effectiveness of surgical modalities contributes to a lack of consensus of decision making for surgical interventions. Furthermore, data regarding cost effectiveness, surgical operative time, resources, patient hospital stay and recovery is limited, particularly in the medium term for degenerative lumbar spondylolisthesis. The objective was to compare clinical outcomes following different fixation interventions treating degenerative lumbar spondylolisthesis. A retrospective cohort study using the British Spine Registry (BSR) of 1,838 patients aged ≥18 years. Five hundred and five patients undergoing posterior lumbar interbody fusion (PLIF) and 1,333 undergoing transforaminal lumbar interbody fusion (TLIF) with 6 months follow-up, were compared. Demographics, Oswestry Disability Index (ODI), Numerical Rating Scale (NRS) [back and leg], quality of life, complications and cost effectiveness were analysed. NRS (back and leg) demonstrated a statistically significant difference favouring TLIF at 6 months (P=0.04) and (P<0.05) respectively. There was no difference in ODI improvement at 6 months between PLIF and TLIF (P=0.620), but there was a statistically significant difference in ODI scores preoperatively between PLIF and TLIF (P<0.001). EQ-5D-5L-Health VAS (P=0.136) and EQ-5D-5L (P=0.655) did not show a statistically significant difference in improvement between PLIF and TLIF. Dural tear was the most common complication and was higher in the PLIF group (5.7%) but not statistically significant. Estimated blood loss was greater for PLIF (P=0.041). Implant cost (P<0.001) was higher for TLIF whereas theatre time was higher for PLIF (P=0.031). Both PLIF and TLIF result in clinically significant improvements in ODI, NRS back pain and NRS leg pain, with superiority of TLIF for improvements in back and leg pain. Surgeons appeared to use ODI preoperatively to decide intervention with comparable improvements for both approaches. Average theatre time and blood loss volume was higher for PLIF. Factors like implant costs and costs of consumables were higher for TLIF. Costs merit further evaluation.

Clinical and Cost-Effectiveness of Lumbar Interbody Fusion Using Tritanium Posterolateral Cage (vs. Propensity-Matched Cohort of PEEK Cage).

Surgical management of degenerative lumbar spine disorders is effective at improving patient pain, disability, and quality of life; however, obtaining a durable posterolateral fusion after decompression remains a challenge. Interbody fusion technologies are viable means of improving fusion rates in the lumbar spine, specifically various graft materials including autograft, structural allograft, titanium, and polyether ether ketone. This study assesses the effectiveness of Tritanium posterolateral cage in the treatment of degenerative disk disease. Nearest-neighbor 1:1 matched control transforaminal lumbar interbody fusion with PEEK vs. Tritanium posterior lumbar (PL) cage interbody fusion patients were identified using propensity scoring from patients that underwent elective surgery for degenerative disk diseases. Line graphs were generated to compare the trajectories of improvement in patient-reported outcomes (PROs) from baseline to 3 and 12 months postoperatively. The nominal data were compared via the χ2 test, while the continuous data were compared via Student's t-test. The two groups had no difference regarding either the 3- or 12-month Euro-Qol-5D (EQ-5D), numeric rating scale (NRS) leg pain, and NRS back pain; however, the Tritanium interbody cage group had better Oswestry Disability Index (ODI) scores compared to the control group of the PEEK interbody cage at both 3 and 12 months (p=0.013 and 0.048). Our results indicate the Tritanium cage is an effective alternative to the previously used PEEK cage in terms of PROs, surgical safety, and radiological parameters of surgical success. The Tritanium cohort showed better ODI scores, higher fusion rates, lower subsidence, and lower indirect costs associated with surgical management, when compared to the propensity-matched PEEK cohort.

Comparison of the efficacy of acupuncture at the TUNG’s extra points and the traditional Chinese medicine points for elderly patients with chronic low back pain in Thailand

ObjectiveTo compare the efficacy of acupuncture at TUNG’s extra points and traditional Chinese medicine (TCM) points for elderly patients with chronic low back pain (CLBP) in Thailand.MethodsA single-blinded, randomized controlled trial with 84 elderly volunteers with CLBP was designed. The patients were randomly assigned either to the group getting acupuncture at TUNG’s extra points or to the group getting acupuncture at TCM points. The treatment period was 30 min per session for seven consecutive days. Before and after treatment, the score of the numeric rating scale (NRS), the back range of motion (BROM), and the back strength were measured and compared.ResultsAfter treatment, both groups were found with decreased NRS scores and increased BROM (P<0.05), but with no statistical difference in their back strength in comparison with that before treatment in the same group (P>0.05). Regarding the between-group comparisons, no significant differences were found in the NRS score or BROM in the direction of forward flexion and right lateral flexion or the back strength after treatment (P>0.05). However, statistical differences were found in the BROM in directions of back extension (P<0.01) and left lateral flexion (P<0.05).ConclusionAcupuncture at TUNG’s extra points can decrease the low back pain NRS score and increase the back strength and the BROM in directions of forward flexion and right lateral flexion, equivalent to acupuncture at TCM points. Acupuncture at TCM points has a better effect in increasing the BROM in directions of back extension and left lateral flexion; acupuncture at TUNG’s extra points is suitable for elderly CLBP patients, and it should be supported and promoted.

Outcomes of operative treatment for adult spinal deformity: a prospective multicenter assessment with mean 4-year follow-up.

The current literature has primarily focused on the 2-year outcomes of operative adult spinal deformity (ASD) treatment. Longer term durability is important given the invasiveness, complications, and costs of these procedures. The aim of this study was to assess minimum 3-year outcomes and complications of ASD surgery. Operatively treated ASD patients were assessed at baseline, follow-up, and through mailings. Patient-reported outcome measures (PROMs) included scores on the Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r) questionnaire, mental component summary (MCS) and physical component summary (PCS) of the SF-36, and numeric rating scale (NRS) for back and leg pain. Complications were classified as perioperative (≤ 90 days), delayed (90 days to 2 years), and long term (≥ 2 years). Analyses focused on patients with minimum 3-year follow-up. Of 569 patients, 427 (75%) with minimum 3-year follow-up (mean ± SD [range] 4.1 ± 1.1 [3.0-9.6] years) had a mean age of 60.8 years and 75% were women. Operative treatment included a posterior approach for 426 patients (99%), with a mean ± SD 12 ± 4 fusion levels. Anterior lumbar interbody fusion was performed in 35 (8%) patients, and 89 (21%) underwent 3-column osteotomy. All PROMs improved significantly from baseline to last follow-up, including scores on ODI (45.4 to 30.5), PCS (31.0 to 38.5), MCS (45.3 to 50.6), SRS-22r total (2.7 to 3.6), SRS-22r activity (2.8 to 3.5), SRS-22r pain (2.3 to 3.4), SRS-22r appearance (2.4 to 3.5), SRS-22r mental (3.4 to 3.7), SRS-22r satisfaction (2.7 to 4.1), NRS for back pain (7.1 to 3.8), and NRS for leg pain (4.8 to 3.0) (all p < 0.001). Degradations in some outcome measures were observed between the 2-year and last follow-up evaluations, but the magnitudes of these degradations were modest and arguably not clinically significant. Overall, 277 (65%) patients had at least 1 complication, including 185 (43%) perioperative, 118 (27%) delayed, and 56 (13%) long term. Notably, the 142 patients who did not achieve 3-year follow-up were similar to the study patients in terms of demographic characteristics, deformities, and baseline PROMs and had similar rates and types of complications. This prospective multicenter analysis demonstrated that operative ASD treatment provided significant improvement of health-related quality of life at minimum 3-year follow-up (mean 4.1 years), suggesting that the benefits of surgery for ASD remain durable at longer follow-up. These findings should prove useful for counseling, cost-effectiveness assessments, and efforts to improve the safety of care.

추나요법을 동반한 한방복합치료로 호전된 요추 전만각 1례: 증례보고

Objectives :To introduce a case of a traffic accident trauma in a patient with lumbar kyphosis and straightened lumbar curvature, where the Korean medicine treatment with Chuna manual therapy (CMT) improved lumbar lordotic angle(LLA) and lower back pain.&#x0D; Methods : Chuna manual therapy and other Korean medicine treatments; were pro- vided to patient with a flat back posture and low back pain due to the trauma from a traffic accident. Cobb’s angle to evaluate LLA and numeric rating scale (NRS) to eval- uate pain were compared before and after the treatment.&#x0D; Results : There was a significant increase in LLA to reach the normal range and a de- crease in low back pain NRS after Korean medicine treatment with CMT for 9 days of admission treatment and 3 weeks of outpatient treatment.&#x0D; Conclusions :This study suggests that Korean medicine treatment, including CMT, may improve low back pain as well as LLA of straightened lumbar curvatures in patients.

Complications, Readmissions, Revisions, and Patient-reported Outcomes in Patients With Parkinson Disease Undergoing Elective Spine Surgery: A Propensity-matched Analysis.

Retrospective analysis on prospectively collected data. To determine the effectiveness of elective spine surgery in patients with Parkinson disease (PD). PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness. Data from the Quality Outcomes Database (QOD) was queried between April 2013 and January 2019. Three surgical groups were identified: (1) elective lumbar surgery, (2) elective cervical surgery for myelopathy, (3) elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5:1 ratio without replacement based on American Society of Anesthesiology grade, arthrodesis, surgical approach, number of operated levels, age, and baseline Oswestry Disability Index, Numerical Rating Scale (NRS) extremity pain, NRS back pain, and EuroQol 5-Dimensions (EQ-5D). The mean difference was calculated for continuous outcomes (Oswestry Disability Index, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12mo after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality). For the lumbar analysis, PD patients had a higher rate of reoperation at 12 months (risk difference=0.057, P =0.015) and lower mean EQ-5D score at 12 months (mean difference=-0.053, P =0.005) when compared with patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, P =0.005) and lower patient satisfaction at 3 months (risk difference=-0.262, P =0.041) compared with patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, P =0.014) compared with patients without PD. For the matched analysis, in general, patients with and without PD had similar patient-reported outcomes and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.